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					                                                                                  Attachment A-1
                                                                    Northwest Portland Area Indian Health Board
                                                       Estimated FY 2007 Medicare Fee-for-Service Inpatient Hospital Case Rates

                                                                                                         Calculation of Inpatient Hospital Conversion Factor by Facility
Medicare Provider ID                                                                       380089              380037                500050               380007             380009
                                                                                       Legacy Meridian       Providence          S W Washington      Legacy Emanuel        Ohsu Hospital
                                                                                        Park Hospital     Newberg Medical         Medical Center         Hospital           And Clinics
                                                                                                                Center


Operating Amount
   (a) Regional Wage Index                                                                      1.1210               1.1210               1.1210               1.1210              1.1210
   (b) NAOSA, Labor                                                             x             3,397.52             3,397.52             3,397.52             3,397.52            3,397.52
   (c) Adjusted Labor Amount (a)x(b)                                                          3,808.62             3,808.62             3,808.62             3,808.62            3,808.62

   (d) NAOSA, Non-Labor                                                                       1,476.97             1,476.97             1,476.97             1,476.97            1,476.97
   (e) COLA                                                                     x               1.0000               1.0000               1.0000               1.0000              1.0000
    (f) Adjusted NonLabor Amount (d)x(e)                                                      1,476.97             1,476.97             1,476.97             1,476.97            1,476.97

   (g) Total Adjusted Operating Amount (c)+(f)                                                5,285.59             5,285.59             5,285.59             5,285.59            5,285.59

   (h) DSH %                                                                                       -                0.0430                0.1274               0.2434              0.2562
    (i) IME %                                                                                      -                   -                  0.0297               0.0650              0.2903

    (j) Disproportionate Share Amount (g)x(h)                                                     -                 227.28                673.38             1,286.51            1,354.17
   (k) Indirect Medical Education Amount (g)x(i)                                                  -                    -                  157.04               343.78            1,534.66

    (l) Subtotal Operating (g)+(j)+(k)                                                        5,285.59             5,512.87             6,116.02             6,915.88            8,174.41

Capital Amount
   (o) GAF                                                                                     1.0814               1.0814                1.0814               1.0814              1.0814
   (p) National Capital Standard Federal Rate                                   x              427.03               427.03                427.03               427.03              427.03
   (q) Large Urban Area Adj.                                                    x                 1.03                 1.03                  1.03                 1.03                1.03
    (r) COLA                                                                    x              1.0000               1.0000                1.0000               1.0000              1.0000
   (s) Adjusted Capital Amount (o)x(p)x(q)x(r)                                                 475.64               475.64                475.64               475.64              475.64

    (t) DSH %                                                                                  0.0212                   -                 0.0595               0.0901              0.0935
   (u) IME %                                                                                      -                     -                 0.0202               0.0587              0.2517

    (v) Disproportionate Share Amount (s)x(t)                                                   10.08                   -                  28.30                42.86               44.47
   (w) Indirect Medical Education Amount (s)x(u)                                                  -                     -                   9.60                27.92              119.70

   (x) Subtotal Capital (q)+(t)+(u)                                                            485.73               475.64                513.54               546.42              639.81

Total Amount (l)+(x)                                                                          5,771.32             5,988.51             6,629.56             7,462.30            8,814.23

Pass Through Amount (per diem)²                                                                   9.66                 8.11                33.48                75.23              290.94

                                                                                                                 Case Rates for Specific DRGs by Hospital
                                                                                                            Providence
                                                                              DRG      Legacy Meridian    Newberg Medical     S W Washington     Legacy Emanuel            Ohsu Hospital
DRG DRG Description                                                           Weight    Park Hospital         Center           Medical Center        Hospital               And Clinics

  1    Craniotomy Age >17 W Cc                                                3.4651          $19,998              $20,751              $22,972              $25,858              $30,542
  88   Chronic Obstructive Pulmonary Disease                                  0.8878           $5,124               $5,317               $5,886               $6,625               $7,825
  89   Simple Pneumonia & Pleurisy Age >17 W Cc                               1.0376           $5,988               $6,214               $6,879               $7,743               $9,146
 106   Coronary Bypass W Ptca                                                 6.7383          $38,889              $40,352              $44,672              $50,283              $59,393
 143   Chest Pain                                                             0.5637           $3,253               $3,376               $3,737               $4,206               $4,969


Notes:
    1) Outlier payments are not shown and are assumed to be zero.
    2) The Pass Through Amount is not used in the DRG Case Rate calculation. Pass Through payments are equal to the LOS times the Pass Through per
       diem.




    pai 7/26/2012 2:18 PM
                                                                                            Milliman
    C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [IPPS]                                                                                                Page 1 of 706
                                                                   Attachment A-2
                                                    Northwest Portland Area Indian Health Board
                                         Outlier Calculation - Ohsu Hospital And Clinics (Provider ID 380009)
                                                                                                  Non-Transfer          Line
                     Input Data
                     DRG                                                                                        7
                          DRG Relative Weight                                                              2.6609              a
                     Operating
                          Standardized Amounts
                                Labor-related                                                             3,397.52          b
                                Nonlabor-related                                                          1,476.97          c
                          CBSA Wage Index                                                                   1.1210          d
                          COLA                                                                              1.0000         d1
                          IME Operating Adjustment Factor                                                   0.2903          e
                          DSH Operating Adjustment Factor                                                   0.2562          f
                          Labor Related Portion                                                              0.697          g
                          Nonlabor Related Portion                                                           0.303          h

                     Capital
                           Federal Capital Rate                                                            427.03           j
                           Add-on                                                                           1.030           k
                           COLA                                                                             1.000          k1
                           MSA Geographic Adjustment Factor                                                1.0814           l
                           IME Capital Adjustment Factor                                                   0.2517          m
                           DSH Capital Adjustment Factor                                                   0.0935           n




                     Step 1: Federal Rates
                     Federal Rate for Operating Costs
                       a x [(b x d)+(c x d1)] x (1+e+f) =                                              $21,751.30              i
                     Federal Rate for Capital Costs
                               a * j * k * k1 * l * (1+m+n)=                                            $1,702.48              o

                     Step 2: Determine Costs:
                           Billed Charges                                                                $200,000              p
                           Operating Cost to Charge Ratio                                                  0.3970              q
                     Operating Costs = (Billed Charges x Operating Cost to Charge Ratio)
                           (p * q) =                                                                      $79,400              r
                     Capital Cost to Charge Ratio                                                          0.0300              s
                     Capital Costs = (Billed Charges x Capital Cost to Charge Ratio)
                           (p * s) =                                                                       $6,000              t

                     Step 3: Determine Outlier Threshold                                              FY2007
                            Fixed Loss Threshold                                                         $24,485               u
                            Operating CCR to Total CCR                                                    0.9297               v
                           ( Operating Threshold =
                     Operating Outlier CCR )/ (Operating CCR + Capital CCR) (q/(q+s))=
                     {[Fixed Loss Threshold x ((Labor
                     related portion x MSA Wage
                     Index) + Nonlabor related portion x
                              (u * ((g*d)+(h*d1))*v)+i =                                               $46,435.95          w
                            Threshold Adjustment Factor - for Transfers                                     1.000          w1
                            Adjusted Operating Outlier Threshold (w x w1)                              $46,435.95          w2

                           Capital CCR to Total CCR
                           [Capital CCR ) (Operating CCR + Capital CCR)] (s/(q+s))=                        0.0703              x
                     Capital Outlier Threshold = (Fixed
                     Loss Threshold x Geographic
                     Adjustment Factor x Add-On x
                              (u * l * k * k1 * x ) + o =                                               $3,618.57           y
                           Adjusted Capital Outlier Threshold    (y x w1)                               $3,618.57          y1

                     Step 4: Determine Outlier Payment:
                           Marginal Cost Factor                                                                  0.80          z
                           Outlier Payment = (Costs - Outlier Threshold) x Marginal Cost Factor
                     Operating                                 (r - w2) *z                             $26,371.24          aa
                     Capital                                   (t - y1) *z                              $1,905.14          bb
                     Total                                     aa+bb                                   $28,276.38




pai 7/26/2012 2:18 PM
                                                                           Milliman
C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [IPPS2]                                                           Page 2 of 706
                                                   Attachment B
                                    Northwest Portland Area Indian Health Board
                                Estimated 2007 Long-Term Care Hospital Case Rates


                                                                                       LTCH Payment Rate by Facility
Medicare Provider ID                                                                    262010             262013
                                                                                        Kindred
                                                                                      Hospital - St.   Select Specialty
                                                                                         Louis             Hospital
Payment Rate Effective 7/1/2006 to 6/30/2007
Labor Cost Calculation
  (a) Unadjusted 2007 Federal Rate                                                       $38,086.04            $38,086.04
 (b) National Labor Share %                                                     x           75.665%               75.665%
  (c) Adjusted Labor Amount (a)x(b)                                                      $28,817.80            $28,817.80

 (d)   Provider Wage Index (Full Wage Index for St. Louis, MO)                               0.8954                0.8954
 (e)   Adjusted Labor Cost (c)x(d)                                                       $25,803.46            $25,803.46

Non-Labor Cost Calculation
 (a) Unadjusted 2007 Federal Rate                                                        $38,086.04            $38,086.04
 (f) National Non-Labor Share % 1-(b)                                           x           24.335%               24.335%
 (g) Non-Labor Cost (a)x(f)                                                               $9,268.24             $9,268.24

Total Payment Rate (e)+(g)                                                               $35,071.70            $35,071.70



                                                                                    Case Rates for Specific DRGs by Hospital
                                                                           FY2007        Kindred
                                                                            DRG       Hospital - St.        Select Specialty
DRG DRG Description                                                        Weight         Louis                 Hospital

   1   Craniotomy Age >17 W Cc                                             1.6835           $59,043               $59,043
  88   Chronic Obstructive Pulmonary Disease                               0.6411           $22,484               $22,484
  89   Simple Pneumonia & Pleurisy Age >17 W Cc                            0.6802           $23,856               $23,856
 106   Coronary Bypass W Ptca                                              1.1625           $40,771               $40,771
 143   Chest Pain                                                          0.4175           $14,642               $14,642




  pai 7/26/2012 2:18 PM
                                                                 Milliman
  C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [LTC]                                                 Page 3 of 706
                                                                Attachment C-1
                                                  Northwest Portland Area Indian Health Board
                                                        Estimated 2007 IRF Case Rates


                                                                                                      Rehab Payment Rate by Facility
Medicare Provider ID                                                                                 260077                  263025

                                                                                                 ST ANTHONYS                SSM
                                                                                                   MEDICAL             REHABILITATION
                                                                                                    CENTER               INSTITUTE
Payment Rate Effective 10/1/2006 to 9/30/2007
Labor Cost Calculation
  (a) Unadjusted 2007 Federal Rate                                                                    $12,981.00               $12,981.00
  (b) National Labor Share %                                                                 x           75.612%                  75.612%
  (c) Adjusted Labor Amount (a)x(b)                                                                    $9,815.19                $9,815.19

 (d)    Provider Wage Index (Full Wage Index for St. Louis, MO)                              x            0.8954                   0.8954
 (e)    Adjusted Labor Cost (c)x(d)                                                                    $8,788.52                $8,788.52

Non-Labor Cost Calculation
 (a) Unadjusted 2007 Federal Rate                                                                     $12,981.00               $12,981.00
 (f) National Non-Labor Share % 1-(b)                                                        x           24.388%                  24.388%
 (g) Non-Labor Cost (a)x(f)                                                                            $3,165.81                $3,165.81

Wage- and Rural- Adjusted Payment
 (h) Wage-Adjusted Federal Payment (e) + (g)                                                          $11,954.33               $11,954.33
 (i) Rural Adjustment Factor (1.213 if Rural)                                                x            1.0000                   1.0000
 (j) Wage- and Rural- Adjusted Federal Payment (h)x(i)                                                $11,954.33               $11,954.33

LIP (DSH) Adjustment Calculation
  (k) LIP (DSH) Adjustment                                                                                0.0306                    0.0743
  (l) LIP (DSH) Adjustment Amount (j)x(k)                                                                $365.96                   $887.94

Teaching Status Adjustment Calculation
 (m) Teaching Status Adjustment                                                                              -                           -
 (n) Teaching Status Adjustment Amount (j)x(m)                                                             $0.00                       $0.00

 (o)    Final FY 2007 Adjusted Federal Case Rate (j)+(l)+(n)                                          $12,320.29               $12,842.27



                                                                                                  Case Rates for Specific CMGs by Hospital
                                                                                  FY2007 CMG     ST ANTHONYS                    SSM
                                                                                   Weight (No      MEDICAL                REHABILITATION
CMG CMG Description (M=motor, C=cognitive, A=age)                                 Comorbidity)      CENTER                  INSTITUTE

 0101   Stroke                       M>51.05                                            0.6347            $7,820                    $8,151
 0302   Non-traumatic brain injury M>35.05 and M<41.05                                  1.0147           $12,501                   $13,031
 0703   Fracture of lower extremity M>28.15 and M<34.15                                 1.0722           $13,210                   $13,769
 1603   Pain syndrome               M<26.75                                             1.1762           $14,491                   $15,105
 1901   Guillian Barre               M>35.95                                            0.9350           $11,519                   $12,008




   pai 7/26/2012 2:18 PM
                                                                       Milliman
   C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [Rehab]                                                 Page 4 of 706
                                                                         Attachment C-2
                                                           Northwest Portland Area Indian Health Board
                                                               Estimated 2007 IRF Outlier Payments

                                                                                       260077                  263025
                                                                                                                SSM
                                                                                  ST ANTHONYS              REHABILITATION
                                                                                 MEDICAL CENTER              INSTITUTE           Line

 Unadjusted 2007 Federal Rate                                                              $12,981.00             $12,981.00     (a)    Billed             $60,000.00
 National Labor Share %                                                                       75.612%                75.612%     (b)    CMG                      0302
 Adjusted Labor Amount (a)x(b)                                                              $9,815.19              $9,815.19     (c)    Tier (1)                     1

 Provider Wage Index (Full Wage Index for St. Louis, MO)                                       0.8954                 0.8954     (d)    (1) If no comorbidity, then set Tier = 4
 Adjusted Labor Cost (c)x(d)                                                                $8,788.52              $8,788.52     (e)


 Unadjusted 2007 Federal Rate                                                              $12,981.00             $12,981.00     (a)
 National Non-Labor Share % 1-(b)                                                             24.388%                24.388%     (f)
 Non-Labor Cost (a)x(f)                                                                     $3,165.81              $3,165.81     (g)


 Wage-Adjusted Federal Payment (e) + (g)                                                   $11,954.33             $11,954.33     (h)
 Rural Adjustment Factor                                                                       1.0000                 1.0000     (i)
 Wage- and Rural- Adjusted Federal Payment (h)x(i)                                         $11,954.33             $11,954.33     (j)


 LIP (DSH) Adjustment                                                                         0.0306                 0.0743      (k)
 LIP (DSH) Adjustment Amount (j)x(k)                                                         $365.96                $887.94      (l)


 Teaching Status Adjustment                                                                        -                       -     (m)
 Teaching Status Adjustment Amount (j)x(m)                                                       $0.00                   $0.00   (n)

 Final FY 2007 Adjusted Federal Case Rate (j)+(l)+(n)                                      $12,320.29             $12,842.27     (o)

                                                                                       260077                  263025

 FY 2007 CMG Weight for CMG 0302, Tier 1                                                        1.4875                  1.4875   (p)
 Final FY 2007 Adjusted Payment Amount
     For CMG 0302, Tier 1 (o)x(p)                                                          $18,326.43             $19,102.87     (q)


                                                                                       260077                  263025


 Billed Amount                                                                             $60,000.00             $60,000.00     (s)
 Cost to Charge Ratio (CCR)                                                                    0.5390                 0.4610     (t)
 CCR Adjusted Billed Amount (s)x(t)                                                        $32,340.00             $27,660.00     (u)

 Fixed Loss Threshold Amount                                                                $5,534.00              $5,534.00     (v)

 Wage, Rural-, and LIP- Adjusted Threshold Amount
    For CMG 0302, Tier 1 [(v)x(b)x(d)+(v)x(f)]*(i)*[(1+(k)+(m)]                             $5,252.33              $5,474.86     (w)

 Final Outlier Threshold Amount (q)+(w)                                                    $23,578.76             $24,577.73     (y)

 Outlier Payment Amount ((u)-(y))*.8                                                        $7,008.99              $2,465.82     (z)




pai 7/26/2012 2:18 PM
                                                                                                    Milliman
C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [Rehab2]                                                                                                          Page 5 of 706
                                                      Attachment D-1
                                            IPPS Psychiatric Prospective Payment
                                            Calculation Steps (Effective 7/1/2006)

        Base Per Diem Calculation
   A       Federal Per Diem Base Rate                   $595.09
   B        -Labor Portion                              $450.27
   C        -Wage Index                                  0.8982 Akron, OH
   D        -Non-Labor Portion                          $144.82
   E        -COLA                                           1.00
   F    Wage Adjusted Per Diem                          $549.25 B x C +D x E
   G     Rural Adjustment Factor                            1.00
   H     Teaching Adjustment Factor                         1.00
    I   Facility Specific Per Diem                     $549.25 F x G x H

        PPS Adjustment Factor
          Day X Adjustment                                  1.31   Day 1, w/ER
          DRG Primary Diagnosis Factor                      0.99   426
          Age Adjustment                                    1.10   65-69
          Comorbidity factor                                1.12   Chronic Obstructed Pulmonary Disease
          Comorbidity factor                                1.06   Tracheostomy
          Comorbidity factor                                1.05   Uncontrolled Diabetes Mellitus with or without complications
          Comorbidity factor
          Comorbidity factor
        PPS Adjustment Factor                              1.78 Product of factors above

        Electroconvulsive Therapy Calculation
   A    Base Rate                                       $256.20
   B        -Labor Portion                              $193.85
   C        -Wage Index                                  0.8982 Akron, OH
   D        -Non-Labor Portion                           $62.35
   E        -COLA                                           1.00
   F    Wage Adjusted Per Diem                          $236.47 B x C +D x E
   G    Days of ECT                                            1
   H    ECT Payment                                    $236.47 F x G

     Day X Calculation
   A   Facility Specific Per Diem                             from above
                                                        $549.25
   B     -PPS Adjustment Factor                               from above
                                                           1.78
   C Adjusted Per Diem                                        AxB
                                                        $976.75
   D ECT Payment                                              from above
                                                        $236.47
   E Total PPS Allowable                            $1,213.22 C + D




pai 7/26/2012 2:18 PM
                                                                Milliman
C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [Psy1]                                                 Page 6 of 706
                                                                                 Attachment D-2
                                                                       IPPS Psychiatric Prospective Payment
                                                                      Rate and Adjustment Factors (Effective (7/1/2006)


Per Diem Rate:                                                                            Variable Per Diem Adjustments:
Federal Per Diem Base Rate                                                      #######   Adjustment Factor
Labor Share (0.75665)                                                           #######   Day 1 -- Facility Without a 24/7 Full-service Emergency Department\     1.19
Non-Labor Share (0.24335)                                                       #######   Day 1 -- Facility With a 24/7 Full-service Emergency Department         1.31
                                                                                          Day 2                                                                   1.12
Facility Adjustments:                                                                     Day 3                                                                   1.08
Rural Adjustment Factor                                                          1.170    Day 4                                                                   1.05
Urban Adjustment Factor                                                          1.000    Day 5                                                                   1.04
Teaching Adjustment:                                                                      Day 6                                                                   1.02
   Teaching Adjustment component                                                 0.515    Day 7                                                                   1.01
   Residents to Beds Ratio (if a teaching facility)                                -      Day 8                                                                   1.01
Teaching Adjustment Factor                                                       1.000    Day 9                                                                   1.00
                                                                                          Day 10                                                                  1.00
Wage Area (See Attachment A)                                                              Day 11                                                                  0.99
                                                                                          Day 12                                                                  0.99
Cost of Living Adjustments (COLAs):                                                       Day 13                                                                  0.99
Alaska                                                                          1.2500    Day 14                                                                  0.99
Hawaii County:                                                                            Day 15                                                                  0.98
 Honolulu                                                                       1.2500    Day 16                                                                  0.97
 Hawaii                                                                         1.1650    Day 17                                                                  0.97
 Kauai                                                                          1.2325    Day 18                                                                  0.96
 Maui                                                                           1.2375    Day 19                                                                  0.95
 Kalawao                                                                        1.2375    Day 20                                                                  0.95
Rest of the U.S.                                                                1.0000    Day 21                                                                  0.95
                                                                                          Day 22+                                                                 0.92
Patient Adjustments:
ECT – Per Treatment (Electroconvulsive Therapy) Base Amount                     #######   Age Adjustments:
Wage Index share (0.75665)                                                      #######   Age (in years)
COLA share (.24335)                                                              $62.35   Under 45                                                                1.00
                                                                                          45 and under 50                                                         1.01
Comorbidity Adjustments:                                                                  50 and under 55                                                         1.02
None                                                                               1.00   55 and under 60                                                         1.04
Artificial Openings-Digestive and Urinary                                          1.08   60 and under 65                                                         1.07
Cardiac Conditions                                                                 1.11   65 and under 70                                                         1.10
Chronic Obstructed Pulmonary Disease                                               1.12   70 and under 75                                                         1.13
Coagulation Factor Deficits                                                        1.13   75 and under 80                                                         1.15
Developmental Disabilities                                                         1.04   80 and over                                                             1.17
Drug and/or Alcohol Induced Mental Disorders                                       1.03
Eating and Conduct Disorders                                                       1.12   DRG Adjustments:
Gangrene                                                                           1.10   Principal Diagnosis
Infectious Diseases                                                                1.07   DRG DRG Definition Adjustment Factor
Oncology Treatment                                                                 1.07   DRG 424 Procedure with principal diagnosis of mental illness            1.22
Poisoning                                                                          1.11   DRG 425 Acute adjustment reaction                                       1.05
Renal Failure, Acute                                                               1.11   DRG 426 Depressive neurosis                                             0.99
Renal Failure, Chronic                                                             1.11   DRG 427 Neurosis, except depressive                                     1.02
Severe Musculoskeletal and Connective Tissue Diseases                              1.09   DRG 428 Disorders of personality                                        1.02
Severe Protein Calorie Malnutrition                                                1.13   DRG 429 Organic disturbances                                            1.03
Tracheostomy                                                                       1.06   DRG 430 Psychosis                                                       1.00
Uncontrolled Diabetes Mellitus with or without complications                       1.05   DRG 431 Childhood disorders                                             0.99
                                                                                          DRG 432 Other mental disorders                                          0.92
                                                                                          DRG 433 Alcohol/Drug use Leave against Medical Advice (LAMA)            0.97
                                                                                          DRG 521 Alcohol/Drug use with comorbid conditions                       1.02
                                                                                          DRG 522 Alcohol/Drug use without comorbid conditions                    0.98
                                                                                          DRG 523 Alcohol/Drug use without rehabilitation                         0.88
                                                                                          DRG 12 Degenerative nervous system disorders                            1.05
                                                                                          DRG 23 Non-traumatic stupor & coma                                      1.07




      pai 7/26/2012 2:18 PM
                                                                                          Milliman
      C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [Psy2]                                                                                   Page 7 of 706
                                 Attachment E
                                 Northwest Portland Area Indian Health Board
                                 Skilled Nursing PPS
                                 Table of RUG Scores, Descriptions and Payment Amounts
                                 FY 2007 Urban Rates
                                 Source: July 1, 2006 Federal Register, CMS Transmittals, other CMS Studies


                                 RUG                                                                                                                Nursing     Therapy Non-case Mix   Non-case Mix      Total
                                 Category      Description                                            ADL* Index   End Splits                     Component   Component Therapy Comp     Component        Rate
                                 RUX           Rehabilitation -- Ultra High plus Extensive Services   16-18                                         $269.88     $240.73                     $72.49    $583.10
                                 RUL           Rehabilitation -- Ultra High plus Extensive Services   7-15                                          $198.86     $240.73                     $72.49    $512.08
                                 RVX           Rehabilitation -- Very High plus Extensive Services    16-18                                         $218.74     $150.86                     $72.49    $442.09
                                 RVL           Rehabilitation -- Very High plus Extensive Services    7-15                                          $188.91     $150.86                     $72.49    $412.26
                                 RHX           Rehabilitation -- High plus Extensive Services         13-18                                         $201.70     $100.57                     $72.49    $374.76
                                 RHL           Rehabilitation -- High plus Extensive Services         7-12                                          $194.59     $100.57                     $72.49    $367.65
                                 RMX           Rehabilitation -- Medium plus Extensive Services       15-18                                         $274.14      $82.38                     $72.49    $429.01
                                 RML           Rehabilitation -- Medium plus Extensive Services       7-14                                          $238.63      $82.38                     $72.49    $393.50
                                 RLX           Rehabilitation -- Low plus Extensive Services          7-18                                          $186.07      $46.01                     $72.49    $304.57
                                 RUC           Rehabilitation -- Ultra High                           16-18                                         $181.81     $240.73                     $72.49    $495.03
                                 RUB           Rehabilitation -- Ultra High                           9-15                                          $140.62     $240.73                     $72.49    $453.84
                                 RUA           Rehabilitation -- Ultra High                           4-8                                           $119.31     $240.73                     $72.49    $432.53
                                 RVC           Rehabilitation -- Very High                            16-18                                         $174.71     $150.86                     $72.49    $398.06
                                 RVB           Rehabilitation -- Very High                            9-15                                          $154.82     $150.86                     $72.49    $378.17
                                 RVA           Rehabilitation -- Very High                            4-8                                           $116.47     $150.86                     $72.49    $339.82
                                 RHC           Rehabilitation -- High                                 13-18                                         $173.29     $100.57                     $72.49    $346.35
                                 RHB           Rehabilitation -- High                                 8-12                                          $157.66     $100.57                     $72.49    $330.72
                                 RHA           Rehabilitation -- High                                 4-7                                           $133.52     $100.57                     $72.49    $306.58
                                 RMC           Rehabilitation -- Medium                               15-18                                         $163.35      $82.38                     $72.49    $318.22
                                 RMB           Rehabilitation -- Medium                               8-14                                          $154.82      $82.38                     $72.49    $309.69
                                 RMA           Rehabilitation -- Medium                               4-7                                           $147.72      $82.38                     $72.49    $302.59
                                 RLB           Rehabilitation -- Low                                  14-18                                         $161.93      $46.01                     $72.49    $280.43
                                 RLA           Rehabilitation -- Low                                  4-13                                          $120.73      $46.01                     $72.49    $239.23
                                 SE3           Extensive Services                                     7-18         Varies with Services Count       $264.19                   $14.09        $72.49    $350.77
                                 SE2           Extensive Services                                     7-18         Varies with Services Count       $211.64                   $14.09        $72.49    $298.22
                                 SE1           Extensive Services                                     7-18         Varies with Services Count       $178.97                   $14.09        $72.49    $265.55
                                 SSC           Special Care                                           17-18                                         $174.71                   $14.09        $72.49    $261.29
                                 SSB           Special Care                                           15-16                                         $160.51                   $14.09        $72.49    $247.09
                                 SSA           Special Care                                           7-14                                          $156.24                   $14.09        $72.49    $242.82
                                 CC2           Clinically Complex                                     17-18        Signs of Depression              $173.29                   $14.09        $72.49    $259.87
                                 CC1           Clinically Complex                                     17-18        No Signs of Depression           $150.56                   $14.09        $72.49    $237.14
                                 CB2           Clinically Complex                                     15-16        Signs of Depression              $139.20                   $14.09        $72.49    $225.78
                                 CB1           Clinically Complex                                     15-16        No Signs of Depression           $129.26                   $14.09        $72.49    $215.84
                                 CA2           Clinically Complex                                     7-14         Signs of Depression              $127.84                   $14.09        $72.49    $214.42
                                 CA1           Clinically Complex                                     7-14         No Signs of Depression           $113.63                   $14.09        $72.49    $200.21
                                 IB2           Impaired Cognition                                     6-10         Nursing Rehabilitation           $105.11                   $14.09        $72.49    $191.69
                                 IB1           Impaired Cognition                                     6-10         Not Receiving Rehabilitation     $102.27                   $14.09        $72.49    $188.85
                                 IA2           Impaired Cognition                                     4-5          Nursing Rehabilitation            $86.64                   $14.09        $72.49    $173.22
                                 IA1           Impaired Cognition                                     4-5          Not Receiving Rehabilitation      $79.54                   $14.09        $72.49    $166.12
                                 BB2           Behavioral Only                                        6-10         Nursing Rehabilitation           $103.69                   $14.09        $72.49    $190.27
                                 BB1           Behavioral Only                                        6-10         Not Receiving Rehabilitation      $98.01                   $14.09        $72.49    $184.59
                                 BA2           Behavioral Only                                        4-5          Nursing Rehabilitation            $85.22                   $14.09        $72.49    $171.80
                                 BA1           Behavioral Only                                        4-5          Not Receiving Rehabilitation      $73.86                   $14.09        $72.49    $160.44
                                 PE2           Physical Function Reduced                              16-18        Nursing Rehabilitation           $120.73                   $14.09        $72.49    $207.31
                                 PE1           Physical Function Reduced                              16-18        Not Receiving Rehabilitation     $116.47                   $14.09        $72.49    $203.05
                                 PD2           Physical Function Reduced                              11-15        Nursing Rehabilitation           $110.79                   $14.09        $72.49    $197.37
                                 PD1           Physical Function Reduced                              11-15        Not Receiving Rehabilitation     $107.95                   $14.09        $72.49    $194.53
                                 PC2           Physical Function Reduced                              9-10         Nursing Rehabilitation           $100.85                   $14.09        $72.49    $187.43
                                 PC1           Physical Function Reduced                              9-10         Not Receiving Rehabilitation      $98.01                   $14.09        $72.49    $184.59
                                 PB2           Physical Function Reduced                              6-8          Nursing Rehabilitation            $78.12                   $14.09        $72.49    $164.70
                                 PB1           Physical Function Reduced                              6-8          Not Receiving Rehabilitation      $76.70                   $14.09        $72.49    $163.28
                                 PA2           Physical Function Reduced                              4-5          Nursing Rehabilitation            $75.28                   $14.09        $72.49    $161.86
                                 PA1           Physical Function Reduced                              4-5          Not Receiving Rehabilitation      $71.02                   $14.09        $72.49    $157.60
                                               * ADL = Activities of Daily Living


pai 7/26/2012 2:18 PM
                                                                                                                                Milliman
C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [SNF]                                                                                                                                           Page 8 of 706
                           Attachment F-1
             Northwest Portland Area Indian Health Board
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                    National            Minimum
HCPCS/                                                                         Relative            Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment            Copayment
25150    Partial removal of ulna                          T      0050           25.1296 $1,544.67                          $308.93
25151    Partial removal of radius                        T      0050           25.1296 $1,544.67                          $308.93
25170    Extensive forearm surgery                CH      T      0051           41.0893 $2,525.68                          $505.14
25210    Removal of wrist bone                            T      0054           25.8758 $1,590.53                          $318.11
25215    Removal of wrist bones                           T      0054           25.8758 $1,590.53                          $318.11
25230    Partial removal of radius                        T      0050           25.1296 $1,544.67                          $308.93
25240    Partial removal of ulna                          T      0050           25.1296 $1,544.67                          $308.93
25246    Injection for wrist x-ray                        N
25248    Remove forearm foreign body                      T      0049     20.8706        $1,282.87                         $256.57
25250    Removal of wrist prosthesis                      T      0050     25.1296        $1,544.67                         $308.93
25251    Removal of wrist prosthesis                      T      0050     25.1296        $1,544.67                         $308.93
25259    Manipulate wrist w/anesthes                      T      0043       1.6857         $103.62                          $20.72
25260    Repair forearm tendon/muscle                     T      0050     25.1296        $1,544.67                         $308.93
25263    Repair forearm tendon/muscle                     T      0050     25.1296        $1,544.67                         $308.93
25265    Repair forearm tendon/muscle                     T      0050     25.1296        $1,544.67                         $308.93
25270    Repair forearm tendon/muscle                     T      0050     25.1296        $1,544.67                         $308.93
25272    Repair forearm tendon/muscle                     T      0050     25.1296        $1,544.67                         $308.93
25274    Repair forearm tendon/muscle                     T      0050     25.1296        $1,544.67                         $308.93
25275    Repair forearm tendon sheath                     T      0050     25.1296        $1,544.67                         $308.93
25280    Revise wrist/forearm tendon                      T      0050     25.1296        $1,544.67                         $308.93
25290    Incise wrist/forearm tendon                      T      0050     25.1296        $1,544.67                         $308.93
25295    Release wrist/forearm tendon                     T      0049     20.8706        $1,282.87                         $256.57
25300    Fusion of tendons at wrist                       T      0050     25.1296        $1,544.67                         $308.93
25301    Fusion of tendons at wrist                       T      0050     25.1296        $1,544.67                         $308.93
25310    Transplant forearm tendon                        T      0051     41.0893        $2,525.68                         $505.14
25312    Transplant forearm tendon                        T      0051     41.0893        $2,525.68                         $505.14
25315    Revise palsy hand tendon(s)                      T      0051     41.0893        $2,525.68                         $505.14
25316    Revise palsy hand tendon(s)              CH      T      0052     66.5800        $4,092.54                         $818.51
25320    Repair/revise wrist joint                        T      0051     41.0893        $2,525.68                         $505.14
25332    Revise wrist joint                               T      0047     33.4505        $2,056.14            537.03       $411.23
25335    Realignment of hand                              T      0051     41.0893        $2,525.68                         $505.14
25337    Reconstruct ulna/radioulnar                      T      0051     41.0893        $2,525.68                         $505.14
25350    Revision of radius                       CH      T      0052     66.5800        $4,092.54                         $818.51
25355    Revision of radius                               T      0051     41.0893        $2,525.68                         $505.14
25360    Revision of ulna                                 T      0050     25.1296        $1,544.67                         $308.93
25365    Revise radius & ulna                             T      0050     25.1296        $1,544.67                         $308.93
25370    Revise radius or ulna                            T      0051     41.0893        $2,525.68                         $505.14
25375    Revise radius & ulna                             T      0051     41.0893        $2,525.68                         $505.14
25390    Shorten radius or ulna                           T      0050     25.1296        $1,544.67                         $308.93
25391    Lengthen radius or ulna                          T      0051     41.0893        $2,525.68                         $505.14
25392    Shorten radius & ulna                            T      0050     25.1296        $1,544.67                         $308.93
25393    Lengthen radius & ulna                           T      0051     41.0893        $2,525.68                         $505.14
25394    Repair carpal bone, shorten                      T      0053     16.1540          $992.95        $253.49          $198.59
25400    Repair radius or ulna                            T      0050     25.1296        $1,544.67                         $308.93
25405    Repair/graft radius or ulna                      T      0050     25.1296        $1,544.67                         $308.93
25415    Repair radius & ulna                             T      0050     25.1296        $1,544.67                         $308.93
25420    Repair/graft radius & ulna               CH      T      0052     66.5800        $4,092.54                         $818.51
25425    Repair/graft radius or ulna                      T      0051     41.0893        $2,525.68                         $505.14
25426    Repair/graft radius & ulna                       T      0051     41.0893        $2,525.68                         $505.14
25430    Vasc graft into carpal bone                      T      0054     25.8758
                                                                   Milliman              $1,590.53                         $318.11
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 9 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
25431    Repair nonunion carpal bone                      T      0054           25.8758     $1,590.53                $318.11
25440    Repair/graft wrist bone                  CH      T      0052           66.5800     $4,092.54                $818.51
25441    Reconstruct wrist joint                          T      0425          107.1942     $6,589.01   $1,378.01  $1,317.80
25442    Reconstruct wrist joint                          T      0425          107.1942     $6,589.01      1378.01 $1,317.80
25443    Reconstruct wrist joint                          T      0048           47.4378     $2,915.91                $583.18
25444    Reconstruct wrist joint                          T      0048           47.4378     $2,915.91                $583.18
25445    Reconstruct wrist joint                          T      0048           47.4378     $2,915.91                $583.18
25446    Wrist replacement                                T      0425          107.1942     $6,589.01   $1,378.01  $1,317.80
25447    Repair wrist joint(s)                            T      0047           33.4505     $2,056.14     $537.03    $411.23
25449    Remove wrist joint implant                       T      0047           33.4505     $2,056.14       537.03   $411.23
25450    Revision of wrist joint                          T      0051           41.0893     $2,525.68                $505.14
25455    Revision of wrist joint                          T      0051           41.0893     $2,525.68                $505.14
25490    Reinforce radius                                 T      0051           41.0893     $2,525.68                $505.14
25491    Reinforce ulna                                   T      0051           41.0893     $2,525.68                $505.14
25492    Reinforce radius and ulna                        T      0051           41.0893     $2,525.68                $505.14
25500    Treat fracture of radius                         T      0043            1.6857       $103.62                 $20.72
25505    Treat fracture of radius                         T      0043            1.6857       $103.62                 $20.72
25515    Treat fracture of radius                 CH      T      0063           37.5382     $2,307.40       548.33   $461.48
25520    Treat fracture of radius                         T      0043            1.6857       $103.62                 $20.72
25525    Treat fracture of radius                 CH      T      0063           37.5382     $2,307.40       548.33   $461.48
25526    Treat fracture of radius                 CH      T      0063           37.5382     $2,307.40       548.33   $461.48
25530    Treat fracture of ulna                           T      0043            1.6857         103.62                  20.72
25535    Treat fracture of ulna                           T      0043            1.6857         103.62                  20.72
25545    Treat fracture of ulna                   CH      T      0063           37.5382     $2,307.40     $548.33    $461.48
25560    Treat fracture radius & ulna                     T      0043            1.6857         103.62                  20.72
25565    Treat fracture radius & ulna                     T      0043            1.6857         103.62                  20.72
25574    Treat fracture radius & ulna             CH      T      0064           57.2172        3517.03      835.79     703.41
25575    Treat fracture radius/ulna               CH      T      0064           57.2172     $3,517.03     $835.79    $703.41
25600    Treat fracture radius/ulna                       T      0043            1.6857         103.62                  20.72
25605    Treat fracture radius/ulna                       T      0043            1.6857         103.62                  20.72
25606    Treat fx distal radial                   NI      T      0062           25.5264     $1,569.06     $372.87    $313.81
25607    Treat fx rad extra-articul               NI      T      0064           57.2172        3517.03      835.79     703.41
25608    Treat fx rad intra-articul               NI      T      0064           57.2172     $3,517.03       835.79   $703.41
25609    Treat fx radial 3+ frag                  NI      T      0064           57.2172     $3,517.03     $835.79    $703.41
25611    Treat fracture radius/ulna               CH      D
25620    Treat fracture radius/ulna               CH      D
25622    Treat wrist bone fracture                        T      0043       1.6857            $103.62                          $20.72
25624    Treat wrist bone fracture                        T      0043       1.6857            $103.62                          $20.72
25628    Treat wrist bone fracture                CH      T      0063     37.5382           $2,307.40        $548.33          $461.48
25630    Treat wrist bone fracture                        T      0043       1.6857            $103.62                          $20.72
25635    Treat wrist bone fracture                        T      0043       1.6857            $103.62                          $20.72
25645    Treat wrist bone fracture                CH      T      0063     37.5382           $2,307.40            548.33       $461.48
25650    Treat wrist bone fracture                        T      0043       1.6857            $103.62                          $20.72
25651    Pin ulnar styloid fracture               CH      T      0062     25.5264           $1,569.06        $372.87          $313.81
25652    Treat fracture ulnar styloid             CH      T      0063     37.5382           $2,307.40        $548.33          $461.48
25660    Treat wrist dislocation                          T      0043       1.6857            $103.62                          $20.72
25670    Treat wrist dislocation                  CH      T      0062     25.5264           $1,569.06        $372.87          $313.81
25671    Pin radioulnar dislocation               CH      T      0062     25.5264           $1,569.06        $372.87          $313.81
25675    Treat wrist dislocation                          T      0043       1.6857            $103.62                          $20.72
25676    Treat wrist dislocation                  CH      T      0062     25.5264           $1,569.06        $372.87          $313.81
25680    Treat wrist fracture                             T      0043       1.6857            $103.62                          $20.72
25685    Treat wrist fracture                     CH      T      0062     25.5264           $1,569.06        $372.87          $313.81
25690    Treat wrist dislocation                          T        Milliman 1.6857
                                                                 0043                         $103.62                          $20.72
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 10 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
25695    Treat wrist dislocation                  CH      T      0062           25.5264     $1,569.06     $372.87             $313.81
25800    Fusion of wrist joint                    CH      T      0052           66.5800     $4,092.54                         $818.51
25805    Fusion/graft of wrist joint                      T      0051           41.0893     $2,525.68                         $505.14
25810    Fusion/graft of wrist joint              CH      T      0052           66.5800     $4,092.54                         $818.51
25820    Fusion of hand bones                             T      0053           16.1540       $992.95     $253.49             $198.59
25825    Fuse hand bones with graft                       T      0054           25.8758     $1,590.53                         $318.11
25830    Fusion, radioulnar jnt/ulna              CH      T      0052           66.5800     $4,092.54                         $818.51
25900    Amputation of forearm                            C
25905    Amputation of forearm                            C
25907    Amputation follow-up surgery                     T      0049           20.8706     $1,282.87                         $256.57
25909    Amputation follow-up surgery                     C
25915    Amputation of forearm                            C
25920    Amputate hand at wrist                           C
25922    Amputate hand at wrist                           T      0049           20.8706     $1,282.87                         $256.57
25924    Amputation follow-up surgery                     C
25927    Amputation of hand                               C
25929    Amputation follow-up surgery                     T      0686           14.0346      $862.68                          $172.54
25931    Amputation follow-up surgery                     C
25999    Forearm or wrist surgery                         T      0043       1.6857            $103.62                          $20.72
26010    Drainage of finger abscess                       T      0006       1.4392             $88.46                          $17.69
26011    Drainage of finger abscess                       T      0007     11.1535             $685.58                         $137.12
26020    Drain hand tendon sheath                         T      0053     16.1540             $992.95        $253.49          $198.59
26025    Drainage of palm bursa                           T      0053     16.1540             $992.95        $253.49          $198.59
26030    Drainage of palm bursa(s)                        T      0053     16.1540             $992.95        $253.49          $198.59
26034    Treat hand bone lesion                           T      0053     16.1540             $992.95        $253.49          $198.59
26035    Decompress fingers/hand                          T      0053     16.1540             $992.95          253.49         $198.59
26037    Decompress fingers/hand                          T      0053     16.1540             $992.95          253.49         $198.59
26040    Release palm contracture                         T      0054     25.8758           $1,590.53                         $318.11
26045    Release palm contracture                         T      0054     25.8758           $1,590.53                         $318.11
26055    Incise finger tendon sheath                      T      0053     16.1540             $992.95          253.49         $198.59
26060    Incision of finger tendon                        T      0053     16.1540             $992.95          253.49         $198.59
26070    Explore/treat hand joint                         T      0053     16.1540             $992.95          253.49         $198.59
26075    Explore/treat finger joint                       T      0053     16.1540             $992.95          253.49         $198.59
26080    Explore/treat finger joint                       T      0053     16.1540             $992.95          253.49         $198.59
26100    Biopsy hand joint lining                         T      0053     16.1540             $992.95          253.49         $198.59
26105    Biopsy finger joint lining                       T      0053     16.1540             $992.95          253.49         $198.59
26110    Biopsy finger joint lining                       T      0053     16.1540             $992.95        $253.49          $198.59
26115    Removal hand lesion subcut                       T      0022     20.0656           $1,233.39          354.45         $246.68
26116    Removal hand lesion, deep                        T      0022     20.0656           $1,233.39          354.45         $246.68
26117    Remove tumor, hand/finger                        T      0022     20.0656           $1,233.39          354.45         $246.68
26121    Release palm contracture                         T      0054     25.8758           $1,590.53                         $318.11
26123    Release palm contracture                         T      0054     25.8758           $1,590.53                         $318.11
26125    Release palm contracture                         T      0053     16.1540             $992.95            253.49       $198.59
26130    Remove wrist joint lining                        T      0053     16.1540             $992.95            253.49       $198.59
26135    Revise finger joint, each                        T      0054     25.8758           $1,590.53                         $318.11
26140    Revise finger joint, each                        T      0053     16.1540             $992.95        $253.49          $198.59
26145    Tendon excision, palm/finger                     T      0053     16.1540             $992.95          253.49         $198.59
26160    Remove tendon sheath lesion                      T      0053     16.1540             $992.95        $253.49          $198.59
26170    Removal of palm tendon, each                     T      0053     16.1540             $992.95        $253.49          $198.59
26180    Removal of finger tendon                         T      0053     16.1540             $992.95          253.49         $198.59
26185    Remove finger bone                               T      0053     16.1540             $992.95        $253.49          $198.59
26200    Remove hand bone lesion                          T      0053     16.1540             $992.95          253.49         $198.59
26205    Remove/graft bone lesion                         T      0054     25.8758
                                                                   Milliman                 $1,590.53                         $318.11
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 11 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
26210    Removal of finger lesion                         T      0053      16.1540       $992.95     $253.49    $198.59
26215    Remove/graft finger lesion                       T      0053      16.1540       $992.95     $253.49    $198.59
26230    Partial removal of hand bone                     T      0053      16.1540       $992.95     $253.49    $198.59
26235    Partial removal, finger bone                     T      0053      16.1540       $992.95     $253.49    $198.59
26236    Partial removal, finger bone                     T      0053      16.1540       $992.95     $253.49    $198.59
26250    Extensive hand surgery                           T      0053      16.1540       $992.95     $253.49    $198.59
26255    Extensive hand surgery                           T      0054      25.8758     $1,590.53                $318.11
26260    Extensive finger surgery                         T      0053      16.1540       $992.95     $253.49    $198.59
26261    Extensive finger surgery                         T      0053      16.1540       $992.95       253.49   $198.59
26262    Partial removal of finger                        T      0053      16.1540       $992.95       253.49   $198.59
26320    Removal of implant from hand                     T      0021      15.1024       $928.31       219.48   $185.66
26340    Manipulate finger w/anesth                       T      0043       1.6857       $103.62                 $20.72
26350    Repair finger/hand tendon                        T      0054      25.8758     $1,590.53                $318.11
26352    Repair/graft hand tendon                         T      0054      25.8758     $1,590.53                $318.11
26356    Repair finger/hand tendon                        T      0054      25.8758     $1,590.53                $318.11
26357    Repair finger/hand tendon                        T      0054      25.8758     $1,590.53                $318.11
26358    Repair/graft hand tendon                         T      0054      25.8758     $1,590.53                $318.11
26370    Repair finger/hand tendon                        T      0054      25.8758     $1,590.53                $318.11
26372    Repair/graft hand tendon                         T      0054      25.8758     $1,590.53                $318.11
26373    Repair finger/hand tendon                        T      0054      25.8758     $1,590.53                $318.11
26390    Revise hand/finger tendon                        T      0054      25.8758     $1,590.53                $318.11
26392    Repair/graft hand tendon                         T      0054      25.8758     $1,590.53                $318.11
26410    Repair hand tendon                               T      0053      16.1540       $992.95     $253.49    $198.59
26412    Repair/graft hand tendon                         T      0054      25.8758     $1,590.53                $318.11
26415    Excision, hand/finger tendon                     T      0054      25.8758     $1,590.53                $318.11
26416    Graft hand or finger tendon                      T      0054      25.8758     $1,590.53                $318.11
26418    Repair finger tendon                             T      0053      16.1540       $992.95       253.49   $198.59
26420    Repair/graft finger tendon                       T      0054      25.8758     $1,590.53                $318.11
26426    Repair finger/hand tendon                        T      0054      25.8758     $1,590.53                $318.11
26428    Repair/graft finger tendon                       T      0054      25.8758     $1,590.53                $318.11
26432    Repair finger tendon                             T      0053      16.1540       $992.95     $253.49    $198.59
26433    Repair finger tendon                             T      0053      16.1540       $992.95     $253.49    $198.59
26434    Repair/graft finger tendon                       T      0054      25.8758     $1,590.53                $318.11
26437    Realignment of tendons                           T      0053      16.1540       $992.95     $253.49    $198.59
26440    Release palm/finger tendon                       T      0053      16.1540       $992.95       253.49   $198.59
26442    Release palm & finger tendon                     T      0054      25.8758     $1,590.53                $318.11
26445    Release hand/finger tendon                       T      0053      16.1540       $992.95       253.49   $198.59
26449    Release forearm/hand tendon                      T      0054      25.8758     $1,590.53                $318.11
26450    Incision of palm tendon                          T      0053      16.1540       $992.95       253.49   $198.59
26455    Incision of finger tendon                        T      0053      16.1540       $992.95       253.49   $198.59
26460    Incise hand/finger tendon                        T      0053      16.1540         992.95      253.49     198.59
26471    Fusion of finger tendons                         T      0053      16.1540         992.95      253.49     198.59
26474    Fusion of finger tendons                         T      0053      16.1540         992.95      253.49     198.59
26476    Tendon lengthening                               T      0053      16.1540       $992.95       253.49   $198.59
26477    Tendon shortening                                T      0053      16.1540         992.95      253.49     198.59
26478    Lengthening of hand tendon                       T      0053      16.1540       $992.95     $253.49    $198.59
26479    Shortening of hand tendon                        T      0053      16.1540       $992.95       253.49   $198.59
26480    Transplant hand tendon                           T      0054      25.8758     $1,590.53                $318.11
26483    Transplant/graft hand tendon                     T      0054      25.8758     $1,590.53                $318.11
26485    Transplant palm tendon                           T      0054      25.8758     $1,590.53                $318.11
26489    Transplant/graft palm tendon                     T      0054      25.8758     $1,590.53                $318.11
26490    Revise thumb tendon                              T      0054      25.8758     $1,590.53                $318.11
26492    Tendon transfer with graft                       T      0054
                                                                   Milliman25.8758     $1,590.53                $318.11
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 12 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
26494    Hand tendon/muscle transfer                      T      0054           25.8758     $1,590.53                $318.11
26496    Revise thumb tendon                              T      0054           25.8758     $1,590.53                $318.11
26497    Finger tendon transfer                           T      0054           25.8758     $1,590.53                $318.11
26498    Finger tendon transfer                           T      0054           25.8758     $1,590.53                $318.11
26499    Revision of finger                               T      0054           25.8758     $1,590.53                $318.11
26500    Hand tendon reconstruction                       T      0053           16.1540       $992.95       253.49   $198.59
26502    Hand tendon reconstruction                       T      0054           25.8758     $1,590.53                $318.11
26504    Hand tendon reconstruction               CH      D
26508    Release thumb contracture                        T      0053           16.1540       $992.95        $253.49          $198.59
26510    Thumb tendon transfer                            T      0054           25.8758     $1,590.53                         $318.11
26516    Fusion of knuckle joint                          T      0054           25.8758     $1,590.53                         $318.11
26517    Fusion of knuckle joints                         T      0054           25.8758     $1,590.53                         $318.11
26518    Fusion of knuckle joints                         T      0054           25.8758     $1,590.53                         $318.11
26520    Release knuckle contracture                      T      0053           16.1540       $992.95          253.49         $198.59
26525    Release finger contracture                       T      0053           16.1540       $992.95          253.49         $198.59
26530    Revise knuckle joint                             T      0047           33.4505     $2,056.14        $537.03          $411.23
26531    Revise knuckle with implant                      T      0048           47.4378     $2,915.91                         $583.18
26535    Revise finger joint                              T      0047           33.4505     $2,056.14        $537.03          $411.23
26536    Revise/implant finger joint                      T      0048           47.4378     $2,915.91                         $583.18
26540    Repair hand joint                                T      0053           16.1540       $992.95            253.49       $198.59
26541    Repair hand joint with graft                     T      0054           25.8758     $1,590.53                         $318.11
26542    Repair hand joint with graft                     T      0053           16.1540       $992.95        $253.49          $198.59
26545    Reconstruct finger joint                         T      0054           25.8758     $1,590.53                         $318.11
26546    Repair nonunion hand                             T      0054           25.8758     $1,590.53                         $318.11
26548    Reconstruct finger joint                         T      0054           25.8758     $1,590.53                         $318.11
26550    Construct thumb replacement                      T      0054           25.8758     $1,590.53                         $318.11
26551    Great toe-hand transfer                          C
26553    Single transfer, toe-hand                        C
26554    Double transfer, toe-hand                        C
26555    Positional change of finger                      T      0054           25.8758     $1,590.53                         $318.11
26556    Toe joint transfer                               C
26560    Repair of web finger                             T      0053     16.1540             $992.95        $253.49          $198.59
26561    Repair of web finger                             T      0054     25.8758           $1,590.53                         $318.11
26562    Repair of web finger                             T      0054     25.8758           $1,590.53                         $318.11
26565    Correct metacarpal flaw                          T      0054     25.8758           $1,590.53                         $318.11
26567    Correct finger deformity                         T      0054     25.8758           $1,590.53                         $318.11
26568    Lengthen metacarpal/finger                       T      0054     25.8758           $1,590.53                         $318.11
26580    Repair hand deformity                            T      0053     16.1540             $992.95            253.49       $198.59
26587    Reconstruct extra finger                         T      0053     16.1540             $992.95            253.49       $198.59
26590    Repair finger deformity                          T      0053     16.1540             $992.95            253.49       $198.59
26591    Repair muscles of hand                           T      0054     25.8758           $1,590.53                         $318.11
26593    Release muscles of hand                          T      0053     16.1540             $992.95            253.49       $198.59
26596    Excision constricting tissue                     T      0053     16.1540             $992.95            253.49       $198.59
26600    Treat metacarpal fracture                        T      0043       1.6857            $103.62                          $20.72
26605    Treat metacarpal fracture                        T      0043       1.6857            $103.62                          $20.72
26607    Treat metacarpal fracture                        T      0043       1.6857            $103.62                          $20.72
26608    Treat metacarpal fracture                CH      T      0062     25.5264           $1,569.06            372.87       $313.81
26615    Treat metacarpal fracture                CH      T      0063     37.5382           $2,307.40            548.33       $461.48
26641    Treat thumb dislocation                          T      0043       1.6857            $103.62                          $20.72
26645    Treat thumb fracture                             T      0043       1.6857            $103.62                          $20.72
26650    Treat thumb fracture                     CH      T      0062     25.5264           $1,569.06        $372.87          $313.81
26665    Treat thumb fracture                     CH      T      0063     37.5382           $2,307.40          548.33         $461.48
26670    Treat hand dislocation                           T        Milliman 1.6857
                                                                 0043                         $103.62                          $20.72
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 13 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
26675    Treat hand dislocation                           T      0043            1.6857       $103.62                 $20.72
26676    Pin hand dislocation                     CH      T      0062           25.5264        1569.06      372.87     313.81
26685    Treat hand dislocation                   CH      T      0063           37.5382     $2,307.40     $548.33    $461.48
26686    Treat hand dislocation                   CH      T      0064           57.2172     $3,517.03       835.79   $703.41
26700    Treat knuckle dislocation                        T      0043            1.6857       $103.62                 $20.72
26705    Treat knuckle dislocation                        T      0043            1.6857         103.62                  20.72
26706    Pin knuckle dislocation                          T      0043            1.6857         103.62                  20.72
26715    Treat knuckle dislocation                CH      T      0063           37.5382         2307.4      548.33     461.48
26720    Treat finger fracture, each                      T      0043            1.6857         103.62                  20.72
26725    Treat finger fracture, each                      T      0043            1.6857       $103.62                 $20.72
26727    Treat finger fracture, each              CH      T      0062           25.5264     $1,569.06       372.87   $313.81
26735    Treat finger fracture, each              CH      T      0063           37.5382         2307.4      548.33     461.48
26740    Treat finger fracture, each                      T      0043            1.6857       $103.62                 $20.72
26742    Treat finger fracture, each                      T      0043            1.6857       $103.62                 $20.72
26746    Treat finger fracture, each              CH      T      0063           37.5382     $2,307.40     $548.33    $461.48
26750    Treat finger fracture, each                      T      0043            1.6857       $103.62                 $20.72
26755    Treat finger fracture, each                      T      0043            1.6857       $103.62                 $20.72
26756    Pin finger fracture, each                CH      T      0062           25.5264     $1,569.06     $372.87    $313.81
26765    Treat finger fracture, each              CH      T      0063           37.5382     $2,307.40     $548.33    $461.48
26770    Treat finger dislocation                         T      0043            1.6857         103.62                  20.72
26775    Treat finger dislocation                         T      0045           14.5947       $897.11     $268.47    $179.42
26776    Pin finger dislocation                   CH      T      0062           25.5264     $1,569.06     $372.87    $313.81
26785    Treat finger dislocation                 CH      T      0062           25.5264     $1,569.06     $372.87    $313.81
26820    Thumb fusion with graft                          T      0054           25.8758     $1,590.53                $318.11
26841    Fusion of thumb                                  T      0054           25.8758     $1,590.53                $318.11
26842    Thumb fusion with graft                          T      0054           25.8758        1590.53                 318.11
26843    Fusion of hand joint                             T      0054           25.8758        1590.53                 318.11
26844    Fusion/graft of hand joint                       T      0054           25.8758        1590.53                 318.11
26850    Fusion of knuckle                                T      0054           25.8758        1590.53                 318.11
26852    Fusion of knuckle with graft                     T      0054           25.8758        1590.53                 318.11
26860    Fusion of finger joint                           T      0054           25.8758        1590.53                 318.11
26861    Fusion of finger jnt, add-on                     T      0054           25.8758        1590.53                 318.11
26862    Fusion/graft of finger joint                     T      0054           25.8758     $1,590.53                $318.11
26863    Fuse/graft added joint                           T      0054           25.8758     $1,590.53                $318.11
26910    Amputate metacarpal bone                         T      0054           25.8758     $1,590.53                $318.11
26951    Amputation of finger/thumb                       T      0053           16.1540         992.95      253.49     198.59
26952    Amputation of finger/thumb                       T      0053           16.1540         992.95      253.49     198.59
26989    Hand/finger surgery                              T      0043            1.6857         103.62                  20.72
26990    Drainage of pelvis lesion                        T      0049           20.8706        1282.87                 256.57
26991    Drainage of pelvis bursa                         T      0049           20.8706        1282.87                 256.57
26992    Drainage of bone lesion                          C
27000    Incision of hip tendon                           T      0049           20.8706     $1,282.87                         $256.57
27001    Incision of hip tendon                           T      0050           25.1296     $1,544.67                         $308.93
27003    Incision of hip tendon                           T      0050           25.1296     $1,544.67                         $308.93
27005    Incision of hip tendon                           C
27006    Incision of hip tendons                          C
27025    Incision of hip/thigh fascia                     C
27030    Drainage of hip joint                            C
27033    Exploration of hip joint                         T      0051           41.0893       2525.68                           505.14
27035    Denervation of hip joint                 CH      T      0051           41.0893       2525.68                           505.14
27036    Excision of hip joint/muscle                     C
27040    Biopsy of soft tissues                           T      0020       6.8083             418.49            107.67               83.7
27041    Biopsy of soft tissues                           T        Milliman 6.8083
                                                                 0020                          418.49            107.67               83.7
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 14 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468         2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate     Copayment Copayment
27047    Remove hip/pelvis lesion                         T      0022           20.0656   1233.39           354.45     246.68
27048    Remove hip/pelvis lesion                         T      0022           20.0656   1233.39           354.45     246.68
27049    Remove tumor, hip/pelvis                         T      0022           20.0656   1233.39           354.45     246.68
27050    Biopsy of sacroiliac joint                       T      0049           20.8706   1282.87                      256.57
27052    Biopsy of hip joint                              T      0049           20.8706   1282.87                      256.57
27054    Removal of hip joint lining                      C
27060    Removal of ischial bursa                         T      0049           20.8706     1282.87                        256.57
27062    Remove femur lesion/bursa                        T      0049           20.8706     1282.87                        256.57
27065    Removal of hip bone lesion                       T      0049           20.8706     1282.87                        256.57
27066    Removal of hip bone lesion                       T      0050           25.1296     1544.67                        308.93
27067    Remove/graft hip bone lesion                     T      0050           25.1296     1544.67                        308.93
27070    Partial removal of hip bone                      C
27071    Partial removal of hip bone                      C
27075    Extensive hip surgery                            C
27076    Extensive hip surgery                            C
27077    Extensive hip surgery                            C
27078    Extensive hip surgery                            C
27079    Extensive hip surgery                            C
27080    Removal of tail bone                             T      0050           25.1296   $1,544.67                      $308.93
27086    Remove hip foreign body                          T      0020            6.8083     $418.49        $107.67        $83.70
27087    Remove hip foreign body                          T      0049           20.8706   $1,282.87                      $256.57
27090    Removal of hip prosthesis                        C
27091    Removal of hip prosthesis                        C
27093    Injection for hip x-ray                          N
27095    Injection for hip x-ray                          N
27096    Inject sacroiliac joint                          B
27097    Revision of hip tendon                           T      0050           25.1296   $1,544.67                      $308.93
27098    Transfer tendon to pelvis                        T      0050           25.1296     1544.67                        308.93
27100    Transfer of abdominal muscle                     T      0051           41.0893     2525.68                        505.14
27105    Transfer of spinal muscle                        T      0051           41.0893     2525.68                        505.14
27110    Transfer of iliopsoas muscle                     T      0051           41.0893     2525.68                        505.14
27111    Transfer of iliopsoas muscle                     T      0051           41.0893   $2,525.68                      $505.14
27120    Reconstruction of hip socket                     C
27122    Reconstruction of hip socket                     C
27125    Partial hip replacement                          C
27130    Total hip arthroplasty                           C
27132    Total hip arthroplasty                           C
27134    Revise hip joint replacement                     C
27137    Revise hip joint replacement                     C
27138    Revise hip joint replacement                     C
27140    Transplant femur ridge                           C
27146    Incision of hip bone                             C
27147    Revision of hip bone                             C
27151    Incision of hip bones                            C
27156    Revision of hip bones                            C
27158    Revision of pelvis                               C
27161    Incision of neck of femur                        C
27165    Incision/fixation of femur                       C
27170    Repair/graft femur head/neck                     C
27175    Treat slipped epiphysis                          C
27176    Treat slipped epiphysis                          C
27177    Treat slipped epiphysis                          C
27178    Treat slipped epiphysis                          C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                   Page 15 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment            Copayment
27179    Revise head/neck of femur                        C
27181    Treat slipped epiphysis                          C
27185    Revision of femur epiphysis                      C
27187    Reinforce hip bones                              C
27193    Treat pelvic ring fracture                       T      0043            1.6857         103.62                            20.72
27194    Treat pelvic ring fracture                       T      0045           14.5947       $897.11             268.47       $179.42
27200    Treat tail bone fracture                         T      0043            1.6857       $103.62                           $20.72
27202    Treat tail bone fracture                 CH      T      0063           37.5382         2307.4            548.33         461.48
27215    Treat pelvic fracture(s)                         C
27216    Treat pelvic ring fracture                       T      0050           25.1296     $1,544.67                          $308.93
27217    Treat pelvic ring fracture                       C
27218    Treat pelvic ring fracture                       C
27220    Treat hip socket fracture                        T      0043            1.6857       $103.62                            $20.72
27222    Treat hip socket fracture                        C
27226    Treat hip wall fracture                          C
27227    Treat hip fracture(s)                            C
27228    Treat hip fracture(s)                            C
27230    Treat thigh fracture                             T      0043            1.6857       $103.62                            $20.72
27232    Treat thigh fracture                             C
27235    Treat thigh fracture                             T      0050           25.1296     $1,544.67                          $308.93
27236    Treat thigh fracture                             C
27238    Treat thigh fracture                             T      0043            1.6857       $103.62                            $20.72
27240    Treat thigh fracture                             C
27244    Treat thigh fracture                             C
27245    Treat thigh fracture                             C
27246    Treat thigh fracture                             T      0043            1.6857       $103.62                            $20.72
27248    Treat thigh fracture                             C
27250    Treat hip dislocation                            T      0043            1.6857       $103.62                           $20.72
27252    Treat hip dislocation                            T      0045           14.5947       $897.11             268.47       $179.42
27253    Treat hip dislocation                            C
27254    Treat hip dislocation                            C
27256    Treat hip dislocation                            T      0043            1.6857       $103.62                           $20.72
27257    Treat hip dislocation                            T      0045           14.5947       $897.11             268.47       $179.42
27258    Treat hip dislocation                            C
27259    Treat hip dislocation                            C
27265    Treat hip dislocation                            T      0043            1.6857         103.62                            20.72
27266    Treat hip dislocation                            T      0045           14.5947       $897.11         $268.47          $179.42
27275    Manipulation of hip joint                        T      0045           14.5947       $897.11         $268.47          $179.42
27280    Fusion of sacroiliac joint                       C
27282    Fusion of pubic bones                            C
27284    Fusion of hip joint                              C
27286    Fusion of hip joint                              C
27290    Amputation of leg at hip                         C
27295    Amputation of leg at hip                         C
27299    Pelvis/hip joint surgery                         T      0043            1.6857       $103.62                           $20.72
27301    Drain thigh/knee lesion                          T      0008           17.5086     $1,076.22                          $215.24
27303    Drainage of bone lesion                          C
27305    Incise thigh tendon & fascia                     T      0049           20.8706     $1,282.87                          $256.57
27306    Incision of thigh tendon                         T      0049           20.8706     $1,282.87                          $256.57
27307    Incision of thigh tendons                        T      0049           20.8706     $1,282.87                          $256.57
27310    Exploration of knee joint                        T      0050           25.1296     $1,544.67                          $308.93
27315    Partial removal, thigh nerve             CH      D
27320    Partial removal, thigh nerve             CH      D        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 16 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
27323    Biopsy, thigh soft tissues               CH      T      0020            6.8083       $418.49       107.67    $83.70
27324    Biopsy, thigh soft tissues                       T      0022           20.0656     $1,233.39       354.45   $246.68
27325    Neurectomy, hamstring                    NI      T      0220           17.8499     $1,097.20                $219.44
27326    Neurectomy, popliteal                    NI      T      0220           17.8499     $1,097.20                $219.44
27327    Removal of thigh lesion                          T      0022           20.0656     $1,233.39       354.45   $246.68
27328    Removal of thigh lesion                          T      0022           20.0656     $1,233.39       354.45   $246.68
27329    Remove tumor, thigh/knee                         T      0022           20.0656     $1,233.39       354.45   $246.68
27330    Biopsy, knee joint lining                        T      0050           25.1296     $1,544.67                $308.93
27331    Explore/treat knee joint                         T      0050           25.1296     $1,544.67                $308.93
27332    Removal of knee cartilage                        T      0050           25.1296     $1,544.67                $308.93
27333    Removal of knee cartilage                        T      0050           25.1296     $1,544.67                $308.93
27334    Remove knee joint lining                         T      0050           25.1296     $1,544.67                $308.93
27335    Remove knee joint lining                         T      0050           25.1296     $1,544.67                $308.93
27340    Removal of kneecap bursa                         T      0049           20.8706     $1,282.87                $256.57
27345    Removal of knee cyst                             T      0049           20.8706     $1,282.87                $256.57
27347    Remove knee cyst                                 T      0049           20.8706     $1,282.87                $256.57
27350    Removal of kneecap                               T      0050           25.1296     $1,544.67                $308.93
27355    Remove femur lesion                              T      0050           25.1296        1544.67                 308.93
27356    Remove femur lesion/graft                        T      0050           25.1296     $1,544.67                $308.93
27357    Remove femur lesion/graft                        T      0050           25.1296        1544.67                 308.93
27358    Remove femur lesion/fixation                     T      0050           25.1296        1544.67                 308.93
27360    Partial removal, leg bone(s)                     T      0050           25.1296        1544.67                 308.93
27365    Extensive leg surgery                            C
27370    Injection for knee x-ray                         N
27372    Removal of foreign body                          T      0022     20.0656             1233.39            354.45         246.68
27380    Repair of kneecap tendon                         T      0049     20.8706             1282.87                           256.57
27381    Repair/graft kneecap tendon                      T      0049     20.8706             1282.87                           256.57
27385    Repair of thigh muscle                           T      0049     20.8706             1282.87                           256.57
27386    Repair/graft of thigh muscle                     T      0049     20.8706             1282.87                           256.57
27390    Incision of thigh tendon                         T      0049     20.8706             1282.87                           256.57
27391    Incision of thigh tendons                        T      0049     20.8706             1282.87                           256.57
27392    Incision of thigh tendons                        T      0049     20.8706             1282.87                           256.57
27393    Lengthening of thigh tendon                      T      0050     25.1296             1544.67                           308.93
27394    Lengthening of thigh tendons                     T      0050     25.1296             1544.67                           308.93
27395    Lengthening of thigh tendons                     T      0051     41.0893             2525.68                           505.14
27396    Transplant of thigh tendon                       T      0050     25.1296             1544.67                           308.93
27397    Transplants of thigh tendons                     T      0051     41.0893             2525.68                           505.14
27400    Revise thigh muscles/tendons                     T      0051     41.0893             2525.68                           505.14
27403    Repair of knee cartilage                         T      0050     25.1296           $1,544.67                         $308.93
27405    Repair of knee ligament                          T      0051     41.0893           $2,525.68                         $505.14
27407    Repair of knee ligament                  CH      T      0052     66.5800           $4,092.54                         $818.51
27409    Repair of knee ligaments                         T      0051     41.0893           $2,525.68                         $505.14
27412    Autochondrocyte implant knee                     T      0042     45.5027           $2,796.96            804.74       $559.39
27415    Osteochondral knee allograft                     T      0042     45.5027           $2,796.96            804.74       $559.39
27418    Repair degenerated kneecap                       T      0051     41.0893           $2,525.68                         $505.14
27420    Revision of unstable kneecap                     T      0051     41.0893           $2,525.68                         $505.14
27422    Revision of unstable kneecap                     T      0051     41.0893             2525.68                           505.14
27424    Revision/removal of kneecap                      T      0051     41.0893             2525.68                           505.14
27425    Lat retinacular release open                     T      0050     25.1296           $1,544.67                         $308.93
27427    Reconstruction, knee                     CH      T      0051     41.0893           $2,525.68                         $505.14
27428    Reconstruction, knee                             T      0052     66.5800           $4,092.54                         $818.51
27429    Reconstruction, knee                             T      0052     66.5800             4092.54                           818.51
27430    Revision of thigh muscles                        T      0051     41.0893
                                                                   Milliman                   2525.68                           505.14
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 17 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
27435    Incision of knee joint                           T      0051           41.0893       2525.68                  505.14
27437    Revise kneecap                                   T      0047           33.4505     $2,056.14       537.03   $411.23
27438    Revise kneecap with implant                      T      0048           47.4378     $2,915.91                $583.18
27440    Revision of knee joint                           T      0047           33.4505       2056.14       537.03     411.23
27441    Revision of knee joint                           T      0047           33.4505     $2,056.14       537.03   $411.23
27442    Revision of knee joint                           T      0047           33.4505     $2,056.14     $537.03    $411.23
27443    Revision of knee joint                           T      0047           33.4505     $2,056.14       537.03   $411.23
27445    Revision of knee joint                           C
27446    Revision of knee joint                           T      0681          205.6815      12642.83                          2528.57
27447    Total knee arthroplasty                          C
27448    Incision of thigh                                C
27450    Incision of thigh                                C
27454    Realignment of thigh bone                        C
27455    Realignment of knee                              C
27457    Realignment of knee                              C
27465    Shortening of thigh bone                         C
27466    Lengthening of thigh bone                        C
27468    Shorten/lengthen thighs                          C
27470    Repair of thigh                                  C
27472    Repair/graft of thigh                            C
27475    Surgery to stop leg growth                       T      0050           25.1296     $1,544.67                         $308.93
27477    Surgery to stop leg growth                       C
27479    Surgery to stop leg growth                       C
27485    Surgery to stop leg growth                       C
27486    Revise/replace knee joint                        C
27487    Revise/replace knee joint                        C
27488    Removal of knee prosthesis                       C
27495    Reinforce thigh                                  C
27496    Decompression of thigh/knee                      T      0049           20.8706     $1,282.87                         $256.57
27497    Decompression of thigh/knee                      T      0049           20.8706     $1,282.87                         $256.57
27498    Decompression of thigh/knee                      T      0049           20.8706     $1,282.87                         $256.57
27499    Decompression of thigh/knee                      T      0049           20.8706     $1,282.87                         $256.57
27500    Treatment of thigh fracture                      T      0043            1.6857       $103.62                          $20.72
27501    Treatment of thigh fracture                      T      0043            1.6857       $103.62                          $20.72
27502    Treatment of thigh fracture                      T      0043            1.6857       $103.62                          $20.72
27503    Treatment of thigh fracture                      T      0043            1.6857       $103.62                          $20.72
27506    Treatment of thigh fracture                      C
27507    Treatment of thigh fracture                      C
27508    Treatment of thigh fracture                      T      0043            1.6857       $103.62                          $20.72
27509    Treatment of thigh fracture              CH      T      0062           25.5264     $1,569.06        $372.87          $313.81
27510    Treatment of thigh fracture                      T      0043            1.6857       $103.62                          $20.72
27511    Treatment of thigh fracture                      C
27513    Treatment of thigh fracture                      C
27514    Treatment of thigh fracture                      C
27516    Treat thigh fx growth plate                      T      0043            1.6857      $103.62                            $20.72
27517    Treat thigh fx growth plate                      T      0043            1.6857      $103.62                            $20.72
27519    Treat thigh fx growth plate                      C
27520    Treat kneecap fracture                           T      0043            1.6857       $103.62                          $20.72
27524    Treat kneecap fracture                   CH      T      0063           37.5382     $2,307.40            548.33       $461.48
27530    Treat knee fracture                              T      0043            1.6857       $103.62                          $20.72
27532    Treat knee fracture                              T      0043            1.6857       $103.62                          $20.72
27535    Treat knee fracture                              C
27536    Treat knee fracture                              C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 18 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                    National              Minimum
HCPCS/                                                                         Relative            Unadjusted             Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment              Copayment
27538    Treat knee fracture(s)                           T      0043            1.6857    103.62                               20.72
27540    Treat knee fracture                              C
27550    Treat knee dislocation                           T      0043            1.6857    $103.62                             $20.72
27552    Treat knee dislocation                           T      0045           14.5947      897.11             268.47          179.42
27556    Treat knee dislocation                           C
27557    Treat knee dislocation                           C
27558    Treat knee dislocation                           C
27560    Treat kneecap dislocation                        T      0043            1.6857     $103.62                           $20.72
27562    Treat kneecap dislocation                        T      0045           14.5947     $897.11         $268.47          $179.42
27566    Treat kneecap dislocation                CH      T      0063           37.5382   $2,307.40         $548.33          $461.48
27570    Fixation of knee joint                           T      0045           14.5947     $897.11         $268.47          $179.42
27580    Fusion of knee                                   C
27590    Amputate leg at thigh                            C
27591    Amputate leg at thigh                            C
27592    Amputate leg at thigh                            C
27594    Amputation follow-up surgery                     T      0049           20.8706   $1,282.87                          $256.57
27596    Amputation follow-up surgery                     C
27598    Amputate lower leg at knee                       C
27599    Leg surgery procedure                            T      0043            1.6857     $103.62                           $20.72
27600    Decompression of lower leg                       T      0049           20.8706   $1,282.87                          $256.57
27601    Decompression of lower leg                       T      0049           20.8706   $1,282.87                          $256.57
27602    Decompression of lower leg                       T      0049           20.8706   $1,282.87                          $256.57
27603    Drain lower leg lesion                           T      0008           17.5086   $1,076.22                          $215.24
27604    Drain lower leg bursa                            T      0049           20.8706   $1,282.87                          $256.57
27605    Incision of achilles tendon                      T      0055           20.4263   $1,255.56             355.34       $251.11
27606    Incision of achilles tendon                      T      0049           20.8706   $1,282.87                          $256.57
27607    Treat lower leg bone lesion                      T      0049           20.8706      1282.87                           256.57
27610    Explore/treat ankle joint                        T      0050           25.1296      1544.67                           308.93
27612    Exploration of ankle joint                       T      0050           25.1296   $1,544.67                          $308.93
27613    Biopsy lower leg soft tissue                     T      0020            6.8083     $418.49           107.67          $83.70
27614    Biopsy lower leg soft tissue                     T      0022           20.0656   $1,233.39         $354.45          $246.68
27615    Remove tumor, lower leg                  CH      T      0050           25.1296   $1,544.67                          $308.93
27618    Remove lower leg lesion                          T      0021           15.1024       928.31            219.48         185.66
27619    Remove lower leg lesion                          T      0022           20.0656      1233.39            354.45         246.68
27620    Explore/treat ankle joint                        T      0050           25.1296      1544.67                           308.93
27625    Remove ankle joint lining                        T      0050           25.1296      1544.67                           308.93
27626    Remove ankle joint lining                        T      0050           25.1296      1544.67                           308.93
27630    Removal of tendon lesion                         T      0049           20.8706      1282.87                           256.57
27635    Remove lower leg bone lesion                     T      0050           25.1296      1544.67                           308.93
27637    Remove/graft leg bone lesion                     T      0050           25.1296   $1,544.67                          $308.93
27638    Remove/graft leg bone lesion                     T      0050           25.1296   $1,544.67                          $308.93
27640    Partial removal of tibia                         T      0051           41.0893   $2,525.68                          $505.14
27641    Partial removal of fibula                        T      0050           25.1296   $1,544.67                          $308.93
27645    Extensive lower leg surgery                      C
27646    Extensive lower leg surgery                      C
27647    Extensive ankle/heel surgery                     T      0051           41.0893   $2,525.68                          $505.14
27648    Injection for ankle x-ray                        N
27650    Repair achilles tendon                           T      0051     41.0893         $2,525.68                          $505.14
27652    Repair/graft achilles tendon             CH      T      0052     66.5800         $4,092.54                          $818.51
27654    Repair of achilles tendon                        T      0051     41.0893         $2,525.68                          $505.14
27656    Repair leg fascia defect                         T      0049     20.8706         $1,282.87                          $256.57
27658    Repair of leg tendon, each                       T      0049     20.8706         $1,282.87                          $256.57
27659    Repair of leg tendon, each                       T      0049     20.8706
                                                                   Milliman               $1,282.87                          $256.57
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 19 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
27664    Repair of leg tendon, each                       T      0049           20.8706     $1,282.87                          $256.57
27665    Repair of leg tendon, each                       T      0050           25.1296     $1,544.67                          $308.93
27675    Repair lower leg tendons                         T      0049           20.8706     $1,282.87                          $256.57
27676    Repair lower leg tendons                         T      0050           25.1296     $1,544.67                          $308.93
27680    Release of lower leg tendon                      T      0050           25.1296     $1,544.67                          $308.93
27681    Release of lower leg tendons                     T      0050           25.1296     $1,544.67                          $308.93
27685    Revision of lower leg tendon                     T      0050           25.1296     $1,544.67                          $308.93
27686    Revise lower leg tendons                         T      0050           25.1296     $1,544.67                          $308.93
27687    Revision of calf tendon                          T      0050           25.1296     $1,544.67                          $308.93
27690    Revise lower leg tendon                          T      0051           41.0893     $2,525.68                          $505.14
27691    Revise lower leg tendon                          T      0051           41.0893     $2,525.68                          $505.14
27692    Revise additional leg tendon                     T      0051           41.0893     $2,525.68                          $505.14
27695    Repair of ankle ligament                         T      0050           25.1296     $1,544.67                          $308.93
27696    Repair of ankle ligaments                        T      0050           25.1296     $1,544.67                          $308.93
27698    Repair of ankle ligament                         T      0050           25.1296     $1,544.67                          $308.93
27700    Revision of ankle joint                          T      0047           33.4505     $2,056.14     $537.03              $411.23
27702    Reconstruct ankle joint                          C
27703    Reconstruction, ankle joint                      C
27704    Removal of ankle implant                         T      0049           20.8706     $1,282.87                          $256.57
27705    Incision of tibia                                T      0051           41.0893     $2,525.68                          $505.14
27707    Incision of fibula                               T      0049           20.8706     $1,282.87                          $256.57
27709    Incision of tibia & fibula                       T      0050           25.1296     $1,544.67                          $308.93
27712    Realignment of lower leg                         C
27715    Revision of lower leg                            C
27720    Repair of tibia                                  C
27722    Repair/graft of tibia                            C
27724    Repair/graft of tibia                            C
27725    Repair of lower leg                              C
27727    Repair of lower leg                              C
27730    Repair of tibia epiphysis                        T      0050     25.1296              1544.67                           308.93
27732    Repair of fibula epiphysis                       T      0050     25.1296              1544.67                           308.93
27734    Repair lower leg epiphyses                       T      0050     25.1296              1544.67                           308.93
27740    Repair of leg epiphyses                          T      0050     25.1296           $1,544.67                          $308.93
27742    Repair of leg epiphyses                          T      0051     41.0893              2525.68                           505.14
27745    Reinforce tibia                          CH      T      0052     66.5800              4092.54                           818.51
27750    Treatment of tibia fracture                      T      0043       1.6857            $103.62                           $20.72
27752    Treatment of tibia fracture                      T      0043       1.6857            $103.62                           $20.72
27756    Treatment of tibia fracture              CH      T      0062     25.5264           $1,569.06         $372.87          $313.81
27758    Treatment of tibia fracture              CH      T      0063     37.5382           $2,307.40         $548.33          $461.48
27759    Treatment of tibia fracture              CH      T      0064     57.2172           $3,517.03           835.79         $703.41
27760    Treatment of ankle fracture                      T      0043       1.6857            $103.62                           $20.72
27762    Treatment of ankle fracture                      T      0043       1.6857            $103.62                           $20.72
27766    Treatment of ankle fracture              CH      T      0063     37.5382           $2,307.40         $548.33          $461.48
27780    Treatment of fibula fracture                     T      0043       1.6857            $103.62                           $20.72
27781    Treatment of fibula fracture                     T      0043       1.6857            $103.62                           $20.72
27784    Treatment of fibula fracture             CH      T      0063     37.5382           $2,307.40         $548.33          $461.48
27786    Treatment of ankle fracture                      T      0043       1.6857            $103.62                           $20.72
27788    Treatment of ankle fracture                      T      0043       1.6857            $103.62                           $20.72
27792    Treatment of ankle fracture              CH      T      0063     37.5382           $2,307.40         $548.33          $461.48
27808    Treatment of ankle fracture                      T      0043       1.6857            $103.62                           $20.72
27810    Treatment of ankle fracture                      T      0043       1.6857            $103.62                           $20.72
27814    Treatment of ankle fracture              CH      T      0063     37.5382           $2,307.40             548.33       $461.48
27816    Treatment of ankle fracture                      T        Milliman 1.6857
                                                                 0043                         $103.62                           $20.72
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 20 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468         2007 CF
                                                                                                        National        Minimum
HCPCS/                                                                         Relative                Unadjusted       Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment        Copayment
27818    Treatment of ankle fracture                      T      0043            1.6857       $103.62                       $20.72
27822    Treatment of ankle fracture              CH      T      0063           37.5382     $2,307.40     $548.33          $461.48
27823    Treatment of ankle fracture              CH      T      0064           57.2172     $3,517.03     $835.79          $703.41
27824    Treat lower leg fracture                         T      0043            1.6857       $103.62                       $20.72
27825    Treat lower leg fracture                         T      0043            1.6857       $103.62                       $20.72
27826    Treat lower leg fracture                 CH      T      0063           37.5382     $2,307.40     $548.33          $461.48
27827    Treat lower leg fracture                 CH      T      0064           57.2172     $3,517.03     $835.79          $703.41
27828    Treat lower leg fracture                 CH      T      0064           57.2172     $3,517.03     $835.79          $703.41
27829    Treat lower leg joint                    CH      T      0063           37.5382     $2,307.40     $548.33          $461.48
27830    Treat lower leg dislocation                      T      0043            1.6857       $103.62                       $20.72
27831    Treat lower leg dislocation                      T      0043            1.6857       $103.62                       $20.72
27832    Treat lower leg dislocation              CH      T      0063           37.5382     $2,307.40     $548.33          $461.48
27840    Treat ankle dislocation                          T      0043            1.6857       $103.62                       $20.72
27842    Treat ankle dislocation                          T      0045           14.5947       $897.11     $268.47          $179.42
27846    Treat ankle dislocation                  CH      T      0063           37.5382     $2,307.40     $548.33          $461.48
27848    Treat ankle dislocation                  CH      T      0063           37.5382     $2,307.40     $548.33          $461.48
27860    Fixation of ankle joint                          T      0045           14.5947       $897.11     $268.47          $179.42
27870    Fusion of ankle joint, open              CH      T      0052           66.5800     $4,092.54                      $818.51
27871    Fusion of tibiofibular joint             CH      T      0052           66.5800     $4,092.54                      $818.51
27880    Amputation of lower leg                          C
27881    Amputation of lower leg                          C
27882    Amputation of lower leg                          C
27884    Amputation follow-up surgery                     T      0049           20.8706     $1,282.87                      $256.57
27886    Amputation follow-up surgery                     C
27888    Amputation of foot at ankle                      C
27889    Amputation of foot at ankle                      T      0050           25.1296     $1,544.67                      $308.93
27892    Decompression of leg                             T      0049           20.8706     $1,282.87                      $256.57
27893    Decompression of leg                             T      0049           20.8706     $1,282.87                      $256.57
27894    Decompression of leg                             T      0049           20.8706     $1,282.87                      $256.57
27899    Leg/ankle surgery procedure                      T      0043            1.6857       $103.62                       $20.72
28001    Drainage of bursa of foot                        T      0007           11.1535       $685.58                      $137.12
28002    Treatment of foot infection                      T      0049           20.8706     $1,282.87                      $256.57
28003    Treatment of foot infection                      T      0049           20.8706     $1,282.87                      $256.57
28005    Treat foot bone lesion                           T      0055           20.4263     $1,255.56        $355.34       $251.11
28008    Incision of foot fascia                          T      0055           20.4263     $1,255.56        $355.34       $251.11
28010    Incision of toe tendon                           T      0055           20.4263     $1,255.56        $355.34       $251.11
28011    Incision of toe tendons                          T      0055           20.4263     $1,255.56        $355.34       $251.11
28020    Exploration of foot joint                        T      0055           20.4263     $1,255.56        $355.34       $251.11
28022    Exploration of foot joint                        T      0055           20.4263     $1,255.56        $355.34       $251.11
28024    Exploration of toe joint                         T      0055           20.4263     $1,255.56        $355.34       $251.11
28030    Removal of foot nerve                    CH      D
28035    Decompression of tibia nerve                     T      0220     17.8499           $1,097.20                      $219.44
28043    Excision of foot lesion                  CH      T      0022     20.0656           $1,233.39        $354.45       $246.68
28045    Excision of foot lesion                          T      0055     20.4263           $1,255.56        $355.34       $251.11
28046    Resection of tumor, foot                         T      0055     20.4263           $1,255.56        $355.34       $251.11
28050    Biopsy of foot joint lining                      T      0055     20.4263           $1,255.56        $355.34       $251.11
28052    Biopsy of foot joint lining                      T      0055     20.4263           $1,255.56        $355.34       $251.11
28054    Biopsy of toe joint lining                       T      0055     20.4263           $1,255.56        $355.34       $251.11
28055    Neurectomy, foot                         NI      T      0220     17.8499           $1,097.20                      $219.44
28060    Partial removal, foot fascia                     T      0055     20.4263           $1,255.56        $355.34       $251.11
28062    Removal of foot fascia                           T      0055     20.4263           $1,255.56        $355.34       $251.11
28070    Removal of foot joint lining                     T      0055     20.4263           $1,255.56        $355.34       $251.11
28072    Removal of foot joint lining                     T      0055     20.4263
                                                                   Milliman                 $1,255.56        $355.34       $251.11
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 21 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
28080    Removal of foot lesion                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28086    Excise foot tendon sheath                        T      0055      20.4263     $1,255.56     $355.34    $251.11
28088    Excise foot tendon sheath                        T      0055      20.4263     $1,255.56     $355.34    $251.11
28090    Removal of foot lesion                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28092    Removal of toe lesions                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28100    Removal of ankle/heel lesion                     T      0055      20.4263     $1,255.56     $355.34    $251.11
28102    Remove/graft foot lesion                         T      0056      40.8559     $2,511.33                $502.27
28103    Remove/graft foot lesion                         T      0056      40.8559     $2,511.33                $502.27
28104    Removal of foot lesion                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28106    Remove/graft foot lesion                         T      0056      40.8559     $2,511.33                $502.27
28107    Remove/graft foot lesion                         T      0056      40.8559     $2,511.33                $502.27
28108    Removal of toe lesions                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28110    Part removal of metatarsal                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28111    Part removal of metatarsal                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28112    Part removal of metatarsal                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28113    Part removal of metatarsal                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28114    Removal of metatarsal heads                      T      0055      20.4263     $1,255.56     $355.34    $251.11
28116    Revision of foot                                 T      0055      20.4263     $1,255.56     $355.34    $251.11
28118    Removal of heel bone                             T      0055      20.4263     $1,255.56     $355.34    $251.11
28119    Removal of heel spur                             T      0055      20.4263     $1,255.56     $355.34    $251.11
28120    Part removal of ankle/heel                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28122    Partial removal of foot bone                     T      0055      20.4263     $1,255.56     $355.34    $251.11
28124    Partial removal of toe                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28126    Partial removal of toe                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28130    Removal of ankle bone                            T      0055      20.4263     $1,255.56     $355.34    $251.11
28140    Removal of metatarsal                            T      0055      20.4263     $1,255.56     $355.34    $251.11
28150    Removal of toe                                   T      0055      20.4263     $1,255.56     $355.34    $251.11
28153    Partial removal of toe                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28160    Partial removal of toe                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28171    Extensive foot surgery                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28173    Extensive foot surgery                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28175    Extensive foot surgery                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28190    Removal of foot foreign body                     T      0019       4.0919       $251.52      $71.87     $50.30
28192    Removal of foot foreign body                     T      0021      15.1024       $928.31     $219.48    $185.66
28193    Removal of foot foreign body                     T      0020       6.8083       $418.49     $107.67     $83.70
28200    Repair of foot tendon                            T      0055      20.4263     $1,255.56     $355.34    $251.11
28202    Repair/graft of foot tendon                      T      0055      20.4263     $1,255.56     $355.34    $251.11
28208    Repair of foot tendon                            T      0055      20.4263     $1,255.56     $355.34    $251.11
28210    Repair/graft of foot tendon                      T      0056      40.8559     $2,511.33                $502.27
28220    Release of foot tendon                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28222    Release of foot tendons                          T      0055      20.4263     $1,255.56     $355.34    $251.11
28225    Release of foot tendon                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28226    Release of foot tendons                          T      0055      20.4263     $1,255.56     $355.34    $251.11
28230    Incision of foot tendon(s)                       T      0055      20.4263     $1,255.56       355.34   $251.11
28232    Incision of toe tendon                           T      0055      20.4263     $1,255.56       355.34   $251.11
28234    Incision of foot tendon                          T      0055      20.4263     $1,255.56     $355.34    $251.11
28238    Revision of foot tendon                          T      0056      40.8559     $2,511.33                $502.27
28240    Release of big toe                               T      0055      20.4263     $1,255.56     $355.34    $251.11
28250    Revision of foot fascia                          T      0055      20.4263     $1,255.56       355.34   $251.11
28260    Release of midfoot joint                         T      0055      20.4263     $1,255.56       355.34   $251.11
28261    Revision of foot tendon                          T      0055      20.4263     $1,255.56     $355.34    $251.11
28262    Revision of foot and ankle                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28264    Release of midfoot joint                         T      0056
                                                                   Milliman40.8559     $2,511.33                $502.27
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 22 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
28270    Release of foot contracture                      T      0055      20.4263     $1,255.56       355.34   $251.11
28272    Release of toe joint, each                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28280    Fusion of toes                                   T      0055      20.4263     $1,255.56     $355.34    $251.11
28285    Repair of hammertoe                              T      0055      20.4263     $1,255.56       355.34   $251.11
28286    Repair of hammertoe                              T      0055      20.4263     $1,255.56       355.34   $251.11
28288    Partial removal of foot bone                     T      0055      20.4263     $1,255.56     $355.34    $251.11
28289    Repair hallux rigidus                            T      0055      20.4263     $1,255.56     $355.34    $251.11
28290    Correction of bunion                             T      0057      28.2349     $1,735.54       475.91   $347.11
28292    Correction of bunion                             T      0057      28.2349     $1,735.54       475.91   $347.11
28293    Correction of bunion                             T      0057      28.2349     $1,735.54     $475.91    $347.11
28294    Correction of bunion                             T      0057      28.2349     $1,735.54     $475.91    $347.11
28296    Correction of bunion                             T      0057      28.2349     $1,735.54       475.91   $347.11
28297    Correction of bunion                             T      0057      28.2349     $1,735.54       475.91   $347.11
28298    Correction of bunion                             T      0057      28.2349     $1,735.54     $475.91    $347.11
28299    Correction of bunion                             T      0057      28.2349     $1,735.54       475.91   $347.11
28300    Incision of heel bone                            T      0056      40.8559     $2,511.33                $502.27
28302    Incision of ankle bone                           T      0055      20.4263     $1,255.56       355.34   $251.11
28304    Incision of midfoot bones                        T      0056      40.8559     $2,511.33                $502.27
28305    Incise/graft midfoot bones                       T      0056      40.8559     $2,511.33                $502.27
28306    Incision of metatarsal                           T      0055      20.4263     $1,255.56     $355.34    $251.11
28307    Incision of metatarsal                           T      0055      20.4263     $1,255.56       355.34   $251.11
28308    Incision of metatarsal                           T      0055      20.4263     $1,255.56       355.34   $251.11
28309    Incision of metatarsals                          T      0056      40.8559     $2,511.33                $502.27
28310    Revision of big toe                              T      0055      20.4263     $1,255.56     $355.34    $251.11
28312    Revision of toe                                  T      0055      20.4263     $1,255.56       355.34   $251.11
28313    Repair deformity of toe                          T      0055      20.4263     $1,255.56       355.34   $251.11
28315    Removal of sesamoid bone                         T      0055      20.4263     $1,255.56     $355.34    $251.11
28320    Repair of foot bones                             T      0056      40.8559     $2,511.33                $502.27
28322    Repair of metatarsals                            T      0056      40.8559     $2,511.33                $502.27
28340    Resect enlarged toe tissue                       T      0055      20.4263     $1,255.56     $355.34    $251.11
28341    Resect enlarged toe                              T      0055      20.4263     $1,255.56     $355.34    $251.11
28344    Repair extra toe(s)                              T      0055      20.4263     $1,255.56     $355.34    $251.11
28345    Repair webbed toe(s)                             T      0055      20.4263     $1,255.56       355.34   $251.11
28360    Reconstruct cleft foot                           T      0056      40.8559     $2,511.33                $502.27
28400    Treatment of heel fracture                       T      0043       1.6857       $103.62                 $20.72
28405    Treatment of heel fracture                       T      0043       1.6857       $103.62                 $20.72
28406    Treatment of heel fracture               CH      T      0062      25.5264     $1,569.06     $372.87    $313.81
28415    Treat heel fracture                      CH      T      0063      37.5382     $2,307.40     $548.33    $461.48
28420    Treat/graft heel fracture                CH      T      0063      37.5382     $2,307.40     $548.33    $461.48
28430    Treatment of ankle fracture                      T      0043       1.6857       $103.62                 $20.72
28435    Treatment of ankle fracture                      T      0043       1.6857       $103.62                 $20.72
28436    Treatment of ankle fracture              CH      T      0062      25.5264     $1,569.06     $372.87    $313.81
28445    Treat ankle fracture                     CH      T      0063      37.5382     $2,307.40     $548.33    $461.48
28450    Treat midfoot fracture, each                     T      0043       1.6857       $103.62                 $20.72
28455    Treat midfoot fracture, each                     T      0043       1.6857       $103.62                 $20.72
28456    Treat midfoot fracture                   CH      T      0062      25.5264     $1,569.06     $372.87    $313.81
28465    Treat midfoot fracture, each             CH      T      0063      37.5382         2307.4      548.33     461.48
28470    Treat metatarsal fracture                        T      0043       1.6857         103.62                  20.72
28475    Treat metatarsal fracture                        T      0043       1.6857       $103.62                 $20.72
28476    Treat metatarsal fracture                CH      T      0062      25.5264     $1,569.06     $372.87    $313.81
28485    Treat metatarsal fracture                CH      T      0063      37.5382     $2,307.40     $548.33    $461.48
28490    Treat big toe fracture                           T      0043       1.6857       $103.62                 $20.72
28495    Treat big toe fracture                           T        Milliman 1.6857
                                                                 0043                    $103.62                 $20.72
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 23 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
28496    Treat big toe fracture                   CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28505    Treat big toe fracture                   CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28510    Treatment of toe fracture                        T      0043            1.6857       $103.62                 $20.72
28515    Treatment of toe fracture                        T      0043            1.6857       $103.62                 $20.72
28525    Treat toe fracture                       CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28530    Treat sesamoid bone fracture                     T      0043            1.6857       $103.62                 $20.72
28531    Treat sesamoid bone fracture             CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28540    Treat foot dislocation                           T      0043            1.6857       $103.62                 $20.72
28545    Treat foot dislocation                   CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28546    Treat foot dislocation                   CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28555    Repair foot dislocation                  CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28570    Treat foot dislocation                           T      0043            1.6857       $103.62                 $20.72
28575    Treat foot dislocation                           T      0043            1.6857       $103.62                 $20.72
28576    Treat foot dislocation                   CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28585    Repair foot dislocation                  CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28600    Treat foot dislocation                           T      0043            1.6857       $103.62                 $20.72
28605    Treat foot dislocation                           T      0043            1.6857       $103.62                 $20.72
28606    Treat foot dislocation                   CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28615    Repair foot dislocation                  CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28630    Treat toe dislocation                            T      0043            1.6857       $103.62                 $20.72
28635    Treat toe dislocation                            T      0045           14.5947       $897.11       268.47   $179.42
28636    Treat toe dislocation                    CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28645    Repair toe dislocation                   CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28660    Treat toe dislocation                            T      0043            1.6857       $103.62                 $20.72
28665    Treat toe dislocation                            T      0045           14.5947       $897.11       268.47   $179.42
28666    Treat toe dislocation                    CH      T      0062           25.5264     $1,569.06       372.87   $313.81
28675    Repair of toe dislocation                CH      T      0063           37.5382     $2,307.40       548.33   $461.48
28705    Fusion of foot bones                             T      0056           40.8559     $2,511.33                $502.27
28715    Fusion of foot bones                             T      0056           40.8559     $2,511.33                $502.27
28725    Fusion of foot bones                             T      0056           40.8559     $2,511.33                $502.27
28730    Fusion of foot bones                             T      0056           40.8559     $2,511.33                $502.27
28735    Fusion of foot bones                             T      0056           40.8559     $2,511.33                $502.27
28737    Revision of foot bones                           T      0056           40.8559     $2,511.33                $502.27
28740    Fusion of foot bones                             T      0056           40.8559     $2,511.33                $502.27
28750    Fusion of big toe joint                          T      0056           40.8559     $2,511.33                $502.27
28755    Fusion of big toe joint                          T      0055           20.4263     $1,255.56       355.34   $251.11
28760    Fusion of big toe joint                          T      0056           40.8559     $2,511.33                $502.27
28800    Amputation of midfoot                            C
28805    Amputation thru metatarsal                       C
28810    Amputation toe & metatarsal                      T      0055     20.4263           $1,255.56            355.34       $251.11
28820    Amputation of toe                                T      0055     20.4263           $1,255.56            355.34       $251.11
28825    Partial amputation of toe                        T      0055     20.4263           $1,255.56            355.34       $251.11
28890    High energy eswt, plantar f              CH      T      0050     25.1296           $1,544.67                         $308.93
28899    Foot/toes surgery procedure                      T      0043       1.6857            $103.62                          $20.72
29000    Application of body cast                         S      0058       1.0607             $65.20                          $13.04
29010    Application of body cast                         S      0426       2.2777            $140.01                          $28.00
29015    Application of body cast                         S      0426       2.2777            $140.01                          $28.00
29020    Application of body cast                         S      0058       1.0607             $65.20                          $13.04
29025    Application of body cast                         S      0058       1.0607             $65.20                          $13.04
29035    Application of body cast                         S      0426       2.2777            $140.01                          $28.00
29040    Application of body cast                         S      0058       1.0607             $65.20                          $13.04
29044    Application of body cast                         S      0426       2.2777            $140.01                          $28.00
29046    Application of body cast                         S        Milliman 2.2777
                                                                 0426                         $140.01                          $28.00
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 24 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
29049    Application of figure eight                      S      0058       1.0607        $65.20                 $13.04
29055    Application of shoulder cast                     S      0426       2.2777       $140.01                 $28.00
29058    Application of shoulder cast                     S      0058       1.0607        $65.20                 $13.04
29065    Application of long arm cast                     S      0426       2.2777       $140.01                 $28.00
29075    Application of forearm cast                      S      0426       2.2777       $140.01                 $28.00
29085    Apply hand/wrist cast                            S      0058       1.0607        $65.20                 $13.04
29086    Apply finger cast                                S      0058       1.0607        $65.20                 $13.04
29105    Apply long arm splint                            S      0058       1.0607        $65.20                 $13.04
29125    Apply forearm splint                             S      0058       1.0607        $65.20                 $13.04
29126    Apply forearm splint                             S      0058       1.0607        $65.20                 $13.04
29130    Application of finger splint                     S      0058       1.0607        $65.20                 $13.04
29131    Application of finger splint                     S      0058       1.0607        $65.20                 $13.04
29200    Strapping of chest                               S      0058       1.0607        $65.20                 $13.04
29220    Strapping of low back                            S      0058       1.0607        $65.20                 $13.04
29240    Strapping of shoulder                            S      0058       1.0607        $65.20                 $13.04
29260    Strapping of elbow or wrist                      S      0058       1.0607        $65.20                 $13.04
29280    Strapping of hand or finger                      S      0058       1.0607        $65.20                 $13.04
29305    Application of hip cast                          S      0426       2.2777       $140.01                 $28.00
29325    Application of hip casts                         S      0426       2.2777       $140.01                 $28.00
29345    Application of long leg cast                     S      0426       2.2777       $140.01                 $28.00
29355    Application of long leg cast                     S      0426       2.2777       $140.01                 $28.00
29358    Apply long leg cast brace                        S      0426       2.2777       $140.01                 $28.00
29365    Application of long leg cast                     S      0426       2.2777       $140.01                 $28.00
29405    Apply short leg cast                             S      0426       2.2777       $140.01                 $28.00
29425    Apply short leg cast                             S      0426       2.2777       $140.01                 $28.00
29435    Apply short leg cast                             S      0426       2.2777       $140.01                 $28.00
29440    Addition of walker to cast                       S      0058       1.0607        $65.20                 $13.04
29445    Apply rigid leg cast                             S      0426       2.2777       $140.01                 $28.00
29450    Application of leg cast                          S      0058       1.0607        $65.20                 $13.04
29505    Application, long leg splint                     S      0058       1.0607        $65.20                 $13.04
29515    Application lower leg splint                     S      0058       1.0607        $65.20                 $13.04
29520    Strapping of hip                                 S      0058       1.0607        $65.20                 $13.04
29530    Strapping of knee                                S      0058       1.0607        $65.20                 $13.04
29540    Strapping of ankle and/or ft                     S      0058       1.0607        $65.20                 $13.04
29550    Strapping of toes                                S      0058       1.0607        $65.20                 $13.04
29580    Application of paste boot                        S      0058       1.0607        $65.20                 $13.04
29590    Application of foot splint                       S      0058       1.0607        $65.20                 $13.04
29700    Removal/revision of cast                         S      0058       1.0607        $65.20                 $13.04
29705    Removal/revision of cast                         S      0058       1.0607        $65.20                 $13.04
29710    Removal/revision of cast                         S      0426       2.2777       $140.01                 $28.00
29715    Removal/revision of cast                         S      0058       1.0607        $65.20                 $13.04
29720    Repair of body cast                              S      0058       1.0607        $65.20                 $13.04
29730    Windowing of cast                                S      0058       1.0607        $65.20                 $13.04
29740    Wedging of cast                                  S      0058       1.0607        $65.20                 $13.04
29750    Wedging of clubfoot cast                         S      0058       1.0607        $65.20                 $13.04
29799    Casting/strapping procedure                      S      0058       1.0607        $65.20                 $13.04
29800    Jaw arthroscopy/surgery                          T      0041      28.6245     $1,759.49                $351.90
29804    Jaw arthroscopy/surgery                          T      0041      28.6245     $1,759.49                $351.90
29805    Shoulder arthroscopy, dx                         T      0041      28.6245     $1,759.49                $351.90
29806    Shoulder arthroscopy/surgery                     T      0042      45.5027     $2,796.96       804.74   $559.39
29807    Shoulder arthroscopy/surgery                     T      0042      45.5027     $2,796.96       804.74   $559.39
29819    Shoulder arthroscopy/surgery                     T      0041      28.6245     $1,759.49                $351.90
29820    Shoulder arthroscopy/surgery                     T      0041
                                                                   Milliman28.6245     $1,759.49                $351.90
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 25 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
29821    Shoulder arthroscopy/surgery                     T      0041      28.6245     $1,759.49                $351.90
29822    Shoulder arthroscopy/surgery                     T      0041      28.6245     $1,759.49                $351.90
29823    Shoulder arthroscopy/surgery                     T      0041      28.6245     $1,759.49                $351.90
29824    Shoulder arthroscopy/surgery                     T      0041      28.6245     $1,759.49                $351.90
29825    Shoulder arthroscopy/surgery                     T      0041      28.6245     $1,759.49                $351.90
29826    Shoulder arthroscopy/surgery                     T      0042      45.5027     $2,796.96       804.74   $559.39
29827    Arthroscop rotator cuff repr                     T      0042      45.5027     $2,796.96       804.74   $559.39
29830    Elbow arthroscopy                                T      0041      28.6245     $1,759.49                $351.90
29834    Elbow arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29835    Elbow arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29836    Elbow arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29837    Elbow arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29838    Elbow arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29840    Wrist arthroscopy                                T      0041      28.6245     $1,759.49                $351.90
29843    Wrist arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29844    Wrist arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29845    Wrist arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29846    Wrist arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29847    Wrist arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29848    Wrist endoscopy/surgery                          T      0041      28.6245     $1,759.49                $351.90
29850    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29851    Knee arthroscopy/surgery                         T      0042      45.5027     $2,796.96     $804.74    $559.39
29855    Tibial arthroscopy/surgery                       T      0042      45.5027     $2,796.96       804.74   $559.39
29856    Tibial arthroscopy/surgery                       T      0041      28.6245     $1,759.49                $351.90
29860    Hip arthroscopy, dx                              T      0041      28.6245     $1,759.49                $351.90
29861    Hip arthroscopy/surgery                          T      0041      28.6245     $1,759.49                $351.90
29862    Hip arthroscopy/surgery                          T      0042      45.5027     $2,796.96       804.74   $559.39
29863    Hip arthroscopy/surgery                          T      0042      45.5027     $2,796.96     $804.74    $559.39
29866    Autgrft implnt, knee w/scope                     T      0042      45.5027     $2,796.96     $804.74    $559.39
29867    Allgrft implnt, knee w/scope                     T      0042      45.5027     $2,796.96     $804.74    $559.39
29868    Meniscal trnspl, knee w/scpe                     T      0042      45.5027     $2,796.96       804.74   $559.39
29870    Knee arthroscopy, dx                             T      0041      28.6245     $1,759.49                $351.90
29871    Knee arthroscopy/drainage                        T      0041      28.6245     $1,759.49                $351.90
29873    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29874    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29875    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29876    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29877    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29879    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29880    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29881    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29882    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29883    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29884    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29885    Knee arthroscopy/surgery                         T      0042      45.5027     $2,796.96       804.74   $559.39
29886    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29887    Knee arthroscopy/surgery                         T      0041      28.6245     $1,759.49                $351.90
29888    Knee arthroscopy/surgery                         T      0042      45.5027     $2,796.96       804.74   $559.39
29889    Knee arthroscopy/surgery                         T      0042      45.5027     $2,796.96       804.74   $559.39
29891    Ankle arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29892    Ankle arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29893    Scope, plantar fasciotomy                        T      0055      20.4263     $1,255.56     $355.34    $251.11
29894    Ankle arthroscopy/surgery                        T      0041
                                                                   Milliman28.6245     $1,759.49                $351.90
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 26 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
29895    Ankle arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29897    Ankle arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29898    Ankle arthroscopy/surgery                        T      0041      28.6245     $1,759.49                $351.90
29899    Ankle arthroscopy/surgery                        T      0042      45.5027     $2,796.96     $804.74    $559.39
29900    Mcp joint arthroscopy, dx                        T      0053      16.1540       $992.95     $253.49    $198.59
29901    Mcp joint arthroscopy, surg                      T      0053      16.1540       $992.95     $253.49    $198.59
29902    Mcp joint arthroscopy, surg                      T      0053      16.1540       $992.95       253.49   $198.59
29999    Arthroscopy of joint                             T      0041      28.6245     $1,759.49                $351.90
30000    Drainage of nose lesion                          T      0251       2.4520       $150.72                 $30.14
30020    Drainage of nose lesion                          T      0251       2.4520       $150.72                 $30.14
30100    Intranasal biopsy                                T      0252       7.5511       $464.15       109.16    $92.83
30110    Removal of nose polyp(s)                         T      0253      16.4266     $1,009.71       282.29   $201.94
30115    Removal of nose polyp(s)                         T      0253      16.4266     $1,009.71     $282.29    $201.94
30117    Removal of intranasal lesion                     T      0253      16.4266     $1,009.71       282.29   $201.94
30118    Removal of intranasal lesion                     T      0254      23.3299     $1,434.04       321.35   $286.81
30120    Revision of nose                                 T      0253      16.4266     $1,009.71     $282.29    $201.94
30124    Removal of nose lesion                           T      0252       7.5511       $464.15       109.16    $92.83
30125    Removal of nose lesion                           T      0256      38.1991     $2,348.02                $469.60
30130    Excise inferior turbinate                        T      0253      16.4266     $1,009.71       282.29   $201.94
30140    Resect inferior turbinate                        T      0254      23.3299     $1,434.04       321.35   $286.81
30150    Partial removal of nose                          T      0256      38.1991     $2,348.02                $469.60
30160    Removal of nose                                  T      0256      38.1991     $2,348.02                $469.60
30200    Injection treatment of nose                      T      0252       7.5511       $464.15       109.16    $92.83
30210    Nasal sinus therapy                              T      0252       7.5511       $464.15       109.16    $92.83
30220    Insert nasal septal button                       T      0252       7.5511       $464.15       109.16    $92.83
30300    Remove nasal foreign body                        X      0340       0.6102        $37.51                  $7.50
30310    Remove nasal foreign body                        T      0253      16.4266     $1,009.71       282.29   $201.94
30320    Remove nasal foreign body                        T      0253      16.4266        1009.71      282.29     201.94
30400    Reconstruction of nose                           T      0256      38.1991        2348.02                  469.6
30410    Reconstruction of nose                           T      0256      38.1991     $2,348.02                $469.60
30420    Reconstruction of nose                           T      0256      38.1991     $2,348.02                $469.60
30430    Revision of nose                                 T      0254      23.3299     $1,434.04     $321.35    $286.81
30435    Revision of nose                                 T      0256      38.1991     $2,348.02                $469.60
30450    Revision of nose                                 T      0256      38.1991     $2,348.02                $469.60
30460    Revision of nose                                 T      0256      38.1991     $2,348.02                $469.60
30462    Revision of nose                                 T      0256      38.1991     $2,348.02                $469.60
30465    Repair nasal stenosis                            T      0256      38.1991     $2,348.02                $469.60
30520    Repair of nasal septum                           T      0254      23.3299     $1,434.04     $321.35    $286.81
30540    Repair nasal defect                              T      0256      38.1991     $2,348.02                $469.60
30545    Repair nasal defect                              T      0256      38.1991     $2,348.02                $469.60
30560    Release of nasal adhesions                       T      0251       2.4520       $150.72                 $30.14
30580    Repair upper jaw fistula                         T      0256      38.1991     $2,348.02                $469.60
30600    Repair mouth/nose fistula                        T      0256      38.1991     $2,348.02                $469.60
30620    Intranasal reconstruction                        T      0256      38.1991        2348.02                  469.6
30630    Repair nasal septum defect                       T      0254      23.3299        1434.04      321.35     286.81
30801    Ablate inf turbinate, superf                     T      0252       7.5511         464.15      109.16      92.83
30802    Cauterization, inner nose                        T      0252       7.5511         464.15      109.16      92.83
30901    Control of nosebleed                             T      0250       1.1791          72.48       25.39       14.5
30903    Control of nosebleed                             T      0250       1.1791        $72.48      $25.39     $14.50
30905    Control of nosebleed                             T      0250       1.1791        $72.48        25.39    $14.50
30906    Repeat control of nosebleed                      T      0250       1.1791        $72.48        25.39    $14.50
30915    Ligation, nasal sinus artery             CH      T      0092      24.8809        1529.38      309.87     305.88
30920    Ligation, upper jaw artery                       T      0092
                                                                   Milliman24.8809        1529.38      309.87     305.88
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 27 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
30930    Ther fx, nasal inf turbinate                     T      0253           16.4266       1009.71       282.29     201.94
30999    Nasal surgery procedure                          T      0251            2.4520         150.72                  30.14
31000    Irrigation, maxillary sinus                      T      0251            2.4520         150.72                  30.14
31002    Irrigation, sphenoid sinus                       T      0252            7.5511         464.15      109.16      92.83
31020    Exploration, maxillary sinus                     T      0254           23.3299       1434.04       321.35     286.81
31030    Exploration, maxillary sinus                     T      0256           38.1991       2348.02                   469.6
31032    Explore sinus, remove polyps                     T      0256           38.1991       2348.02                   469.6
31040    Exploration behind upper jaw                     T      0254           23.3299       1434.04       321.35     286.81
31050    Exploration, sphenoid sinus                      T      0256           38.1991     $2,348.02                $469.60
31051    Sphenoid sinus surgery                           T      0256           38.1991     $2,348.02                $469.60
31070    Exploration of frontal sinus                     T      0254           23.3299     $1,434.04     $321.35    $286.81
31075    Exploration of frontal sinus                     T      0256           38.1991     $2,348.02                $469.60
31080    Removal of frontal sinus                         T      0256           38.1991     $2,348.02                $469.60
31081    Removal of frontal sinus                         T      0256           38.1991     $2,348.02                $469.60
31084    Removal of frontal sinus                         T      0256           38.1991     $2,348.02                $469.60
31085    Removal of frontal sinus                         T      0256           38.1991     $2,348.02                $469.60
31086    Removal of frontal sinus                         T      0256           38.1991     $2,348.02                $469.60
31087    Removal of frontal sinus                         T      0256           38.1991     $2,348.02                $469.60
31090    Exploration of sinuses                           T      0256           38.1991     $2,348.02                $469.60
31200    Removal of ethmoid sinus                         T      0256           38.1991     $2,348.02                $469.60
31201    Removal of ethmoid sinus                         T      0256           38.1991     $2,348.02                $469.60
31205    Removal of ethmoid sinus                         T      0256           38.1991     $2,348.02                $469.60
31225    Removal of upper jaw                             C
31230    Removal of upper jaw                             C
31231    Nasal endoscopy, dx                              T      0072            1.4054        $86.39          $21.27           $17.28
31233    Nasal/sinus endoscopy, dx                        T      0072            1.4054        $86.39          $21.27           $17.28
31235    Nasal/sinus endoscopy, dx                        T      0074           14.7928       $909.28         $292.25          $181.86
31237    Nasal/sinus endoscopy, surg              CH      T      0074           14.7928       $909.28         $292.25          $181.86
31238    Nasal/sinus endoscopy, surg                      T      0074           14.7928       $909.28         $292.25          $181.86
31239    Nasal/sinus endoscopy, surg                      T      0075           21.9512     $1,349.30         $445.92          $269.86
31240    Nasal/sinus endoscopy, surg                      T      0074           14.7928       $909.28         $292.25          $181.86
31254    Revision of ethmoid sinus                        T      0075           21.9512     $1,349.30         $445.92          $269.86
31255    Removal of ethmoid sinus                         T      0075           21.9512     $1,349.30         $445.92          $269.86
31256    Exploration maxillary sinus                      T      0075           21.9512     $1,349.30         $445.92          $269.86
31267    Endoscopy, maxillary sinus                       T      0075           21.9512     $1,349.30         $445.92          $269.86
31276    Sinus endoscopy, surgical                        T      0075           21.9512     $1,349.30         $445.92          $269.86
31287    Nasal/sinus endoscopy, surg                      T      0075           21.9512     $1,349.30         $445.92          $269.86
31288    Nasal/sinus endoscopy, surg                      T      0075           21.9512     $1,349.30         $445.92          $269.86
31290    Nasal/sinus endoscopy, surg                      C
31291    Nasal/sinus endoscopy, surg                      C
31292    Nasal/sinus endoscopy, surg                      T      0075           21.9512     $1,349.30           445.92         $269.86
31293    Nasal/sinus endoscopy, surg                      T      0075           21.9512         1349.3          445.92           269.86
31294    Nasal/sinus endoscopy, surg                      T      0075           21.9512     $1,349.30         $445.92          $269.86
31299    Sinus surgery procedure                          T      0251            2.4520       $150.72                           $30.14
31300    Removal of larynx lesion                         T      0254           23.3299        1434.04            321.35         286.81
31320    Diagnostic incision, larynx                      T      0256           38.1991     $2,348.02                          $469.60
31360    Removal of larynx                                C
31365    Removal of larynx                                C
31367    Partial removal of larynx                        C
31368    Partial removal of larynx                        C
31370    Partial removal of larynx                        C
31375    Partial removal of larynx                        C
31380    Partial removal of larynx                        C        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468          2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
31382    Partial removal of larynx                        C
31390    Removal of larynx & pharynx                      C
31395    Reconstruct larynx & pharynx                     C
31400    Revision of larynx                               T      0256           38.1991     $2,348.02                        $469.60
31420    Removal of epiglottis                            T      0256           38.1991     $2,348.02                        $469.60
31500    Insert emergency airway                          S      0094            2.4233       $148.96          $46.29         $29.79
31502    Change of windpipe airway                        T      0121            2.3587       $144.98          $43.80         $29.00
31505    Diagnostic laryngoscopy                          T      0071            0.7698        $47.32          $11.20          $9.46
31510    Laryngoscopy with biopsy                         T      0074           14.7928       $909.28         $292.25        $181.86
31511    Remove foreign body, larynx                      T      0072            1.4054        $86.39          $21.27         $17.28
31512    Removal of larynx lesion                         T      0074           14.7928       $909.28         $292.25        $181.86
31513    Injection into vocal cord                        T      0072            1.4054        $86.39          $21.27         $17.28
31515    Laryngoscopy for aspiration                      T      0074           14.7928       $909.28         $292.25        $181.86
31520    Dx laryngoscopy, newborn                         T      0072            1.4054        $86.39          $21.27         $17.28
31525    Dx laryngoscopy excl nb                          T      0074           14.7928       $909.28         $292.25        $181.86
31526    Dx laryngoscopy w/oper scope                     T      0075           21.9512     $1,349.30         $445.92        $269.86
31527    Laryngoscopy for treatment                       T      0075           21.9512     $1,349.30         $445.92        $269.86
31528    Laryngoscopy and dilation                        T      0074           14.7928       $909.28         $292.25        $181.86
31529    Laryngoscopy and dilation                        T      0074           14.7928       $909.28         $292.25        $181.86
31530    Laryngoscopy w/fb removal                        T      0075           21.9512     $1,349.30         $445.92        $269.86
31531    Laryngoscopy w/fb & op scope                     T      0075           21.9512     $1,349.30         $445.92        $269.86
31535    Laryngoscopy w/biopsy                            T      0075           21.9512     $1,349.30         $445.92        $269.86
31536    Laryngoscopy w/bx & op scope                     T      0075           21.9512         1349.3          445.92         269.86
31540    Laryngoscopy w/exc of tumor                      T      0075           21.9512         1349.3          445.92         269.86
31541    Larynscop w/tumr exc + scope                     T      0075           21.9512         1349.3          445.92         269.86
31545    Remove vc lesion w/scope                         T      0075           21.9512     $1,349.30         $445.92        $269.86
31546    Remove vc lesion scope/graft                     T      0075           21.9512     $1,349.30         $445.92        $269.86
31560    Laryngoscop w/arytenoidectom                     T      0075           21.9512         1349.3          445.92         269.86
31561    Larynscop, remve cart + scop                     T      0075           21.9512     $1,349.30         $445.92        $269.86
31570    Laryngoscope w/vc inj                            T      0074           14.7928       $909.28           292.25       $181.86
31571    Laryngoscop w/vc inj + scope                     T      0075           21.9512     $1,349.30           445.92       $269.86
31575    Diagnostic laryngoscopy                          T      0072            1.4054          86.39           21.27          17.28
31576    Laryngoscopy with biopsy                         T      0075           21.9512         1349.3          445.92         269.86
31577    Remove foreign body, larynx                      T      0073            3.8463         236.42           69.15          47.28
31578    Removal of larynx lesion                         T      0075           21.9512         1349.3          445.92         269.86
31579    Diagnostic laryngoscopy                          T      0073            3.8463         236.42           69.15          47.28
31580    Revision of larynx                               T      0256           38.1991        2348.02                          469.6
31582    Revision of larynx                               T      0256           38.1991     $2,348.02                        $469.60
31584    Treat larynx fracture                            C
31587    Revision of larynx                               C
31588    Revision of larynx                               T      0256     38.1991              2348.02                          469.6
31590    Reinnervate larynx                               T      0256     38.1991           $2,348.02                        $469.60
31595    Larynx nerve surgery                             T      0256     38.1991           $2,348.02                        $469.60
31599    Larynx surgery procedure                         T      0251       2.4520            $150.72                         $30.14
31600    Incision of windpipe                             T      0254     23.3299           $1,434.04         $321.35        $286.81
31601    Incision of windpipe                             T      0254     23.3299           $1,434.04           321.35       $286.81
31603    Incision of windpipe                             T      0252       7.5511            $464.15           109.16        $92.83
31605    Incision of windpipe                             T      0252       7.5511            $464.15           109.16        $92.83
31610    Incision of windpipe                             T      0254     23.3299           $1,434.04           321.35       $286.81
31611    Surgery/speech prosthesis                        T      0254     23.3299              1434.04          321.35         286.81
31612    Puncture/clear windpipe                          T      0254     23.3299              1434.04          321.35         286.81
31613    Repair windpipe opening                          T      0254     23.3299              1434.04          321.35         286.81
31614    Repair windpipe opening                          T      0256     38.1991
                                                                   Milliman                    2348.02                          469.6
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate     Copayment Copayment
31615    Visualization of windpipe                        T      0076            9.5228     585.35          189.82     117.07
31620    Endobronchial us add-on                          S      0670           32.2854    1984.52           536.1      396.9
31622    Dx bronchoscope/wash                             T      0076            9.5228     585.35          189.82     117.07
31623    Dx bronchoscope/brush                            T      0076            9.5228     585.35          189.82     117.07
31624    Dx bronchoscope/lavage                           T      0076            9.5228     585.35          189.82     117.07
31625    Bronchoscopy w/biopsy(s)                         T      0076            9.5228     585.35          189.82     117.07
31628    Bronchoscopy/lung bx, each                       T      0076            9.5228     585.35          189.82     117.07
31629    Bronchoscopy/needle bx, each                     T      0076            9.5228     585.35          189.82     117.07
31630    Bronchoscopy dilate/fx repr                      T      0415           22.0099     1352.9          459.92     270.58
31631    Bronchoscopy, dilate w/stent                     T      0415           22.0099 $1,352.90           459.92   $270.58
31632    Bronchoscopy/lung bx, add'l                      T      0076            9.5228     585.35          189.82     117.07
31633    Bronchoscopy/needle bx add'l                     T      0076            9.5228     585.35          189.82     117.07
31635    Bronchoscopy w/fb removal                        T      0076            9.5228     585.35          189.82     117.07
31636    Bronchoscopy, bronch stents                      T      0415           22.0099     1352.9          459.92     270.58
31637    Bronchoscopy, stent add-on                       T      0076            9.5228     585.35          189.82     117.07
31638    Bronchoscopy, revise stent                       T      0415           22.0099 $1,352.90         $459.92    $270.58
31640    Bronchoscopy w/tumor excise                      T      0415           22.0099     1352.9          459.92     270.58
31641    Bronchoscopy, treat blockage                     T      0415           22.0099 $1,352.90         $459.92    $270.58
31643    Diag bronchoscope/catheter                       T      0076            9.5228   $585.35           189.82   $117.07
31645    Bronchoscopy, clear airways                      T      0076            9.5228     585.35          189.82     117.07
31646    Bronchoscopy, reclear airway                     T      0076            9.5228     585.35          189.82     117.07
31656    Bronchoscopy, inj for x-ray                      T      0076            9.5228     585.35          189.82     117.07
31700    Insertion of airway catheter             CH      D
31708    Instill airway contrast dye              CH      D
31710    Insertion of airway catheter             CH      D
31715    Injection for bronchus x-ray                     N
31717    Bronchial brush biopsy                           T      0073            3.8463      236.42             69.15              47.28
31720    Clearance of airways                             T      0071            0.7698       47.32              11.2               9.46
31725    Clearance of airways                             C
31730    Intro, windpipe wire/tube                        T      0073            3.8463      236.42             69.15              47.28
31750    Repair of windpipe                               T      0256           38.1991     2348.02                                469.6
31755    Repair of windpipe                               T      0256           38.1991     2348.02                                469.6
31760    Repair of windpipe                               C
31766    Reconstruction of windpipe                       C
31770    Repair/graft of bronchus                         C
31775    Reconstruct bronchus                             C
31780    Reconstruct windpipe                             C
31781    Reconstruct windpipe                             C
31785    Remove windpipe lesion                           T      0254           23.3299   $1,434.04        $321.35          $286.81
31786    Remove windpipe lesion                           C
31800    Repair of windpipe injury                        C
31805    Repair of windpipe injury                        C
31820    Closure of windpipe lesion                       T      0253           16.4266     1009.71            282.29         201.94
31825    Repair of windpipe defect                        T      0254           23.3299     1434.04            321.35         286.81
31830    Revise windpipe scar                             T      0254           23.3299     1434.04            321.35         286.81
31899    Airways surgical procedure                       T      0076            9.5228      585.35            189.82         117.07
32000    Drainage of chest                                T      0070            3.6244      222.78                            44.56
32002    Treatment of collapsed lung                      T      0070            3.6244      222.78                            44.56
32005    Treat lung lining chemically                     T      0070            3.6244      222.78                            44.56
32019    Insert pleural catheter                  CH      T      0652           29.5416     1815.86                           363.17
32020    Insertion of chest tube                          T      0070            3.6244      222.78                            44.56
32035    Exploration of chest                             C
32036    Exploration of chest                             C        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 30 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment           Copayment
32095    Biopsy through chest wall                        C
32100    Exploration/biopsy of chest                      C
32110    Explore/repair chest                             C
32120    Re-exploration of chest                          C
32124    Explore chest free adhesions                     C
32140    Removal of lung lesion(s)                        C
32141    Remove/treat lung lesions                        C
32150    Removal of lung lesion(s)                        C
32151    Remove lung foreign body                         C
32160    Open chest heart massage                         C
32200    Drain, open, lung lesion                         C
32201    Drain, percut, lung lesion                       T      0070            3.6244        222.78                                44.56
32215    Treat chest lining                               C
32220    Release of lung                                  C
32225    Partial release of lung                          C
32310    Removal of chest lining                          C
32320    Free/remove chest lining                         C
32400    Needle biopsy chest lining                       T      0685            6.1384        377.32            115.47              75.46
32402    Open biopsy chest lining                         C
32405    Biopsy, lung or mediastinum                      T      0685            6.1384       $377.32            115.47         $75.46
32420    Puncture/clear lung                              T      0070            3.6244       $222.78                           $44.56
32440    Removal of lung                                  C
32442    Sleeve pneumonectomy                             C
32445    Removal of lung                                  C
32480    Partial removal of lung                          C
32482    Bilobectomy                                      C
32484    Segmentectomy                                    C
32486    Sleeve lobectomy                                 C
32488    Completion pneumonectomy                         C
32491    Lung volume reduction                            C
32500    Partial removal of lung                          C
32501    Repair bronchus add-on                           C
32503    Resect apical lung tumor                         C
32504    Resect apical lung tum/chest                     C
32540    Removal of lung lesion                           C
32601    Thoracoscopy, diagnostic                         T      0069           31.9442     $1,963.55          591.64         $392.71
32602    Thoracoscopy, diagnostic                         T      0069           31.9442     $1,963.55          591.64         $392.71
32603    Thoracoscopy, diagnostic                         T      0069           31.9442     $1,963.55          591.64         $392.71
32604    Thoracoscopy, diagnostic                         T      0069           31.9442     $1,963.55        $591.64          $392.71
32605    Thoracoscopy, diagnostic                         T      0069           31.9442     $1,963.55          591.64         $392.71
32606    Thoracoscopy, diagnostic                         T      0069           31.9442     $1,963.55          591.64         $392.71
32650    Thoracoscopy, surgical                           C
32651    Thoracoscopy, surgical                           C
32652    Thoracoscopy, surgical                           C
32653    Thoracoscopy, surgical                           C
32654    Thoracoscopy, surgical                           C
32655    Thoracoscopy, surgical                           C
32656    Thoracoscopy, surgical                           C
32657    Thoracoscopy, surgical                           C
32658    Thoracoscopy, surgical                           C
32659    Thoracoscopy, surgical                           C
32660    Thoracoscopy, surgical                           C
32661    Thoracoscopy, surgical                           C        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 31 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
32662    Thoracoscopy, surgical                           C
32663    Thoracoscopy, surgical                           C
32664    Thoracoscopy, surgical                           C
32665    Thoracoscopy, surgical                           C
32800    Repair lung hernia                               C
32810    Close chest after drainage                       C
32815    Close bronchial fistula                          C
32820    Reconstruct injured chest                        C
32850    Donor pneumonectomy                              C
32851    Lung transplant, single                          C
32852    Lung transplant with bypass                      C
32853    Lung transplant, double                          C
32854    Lung transplant with bypass                      C
32855    Prepare donor lung, single                       C
32856    Prepare donor lung, double                       C
32900    Removal of rib(s)                                C
32905    Revise & repair chest wall                       C
32906    Revise & repair chest wall                       C
32940    Revision of lung                                 C
32960    Therapeutic pneumothorax                         T      0070            3.6244        222.78                                 44.56
32997    Total lung lavage                                C
32998    Perq rf ablate tx, pul tumor             NI      T      0423           37.3604       2296.47                            459.29
32999    Chest surgery procedure                          T      0070            3.6244        222.78                             44.56
33010    Drainage of heart sac                            T      0070            3.6244        222.78                             44.56
33011    Repeat drainage of heart sac                     T      0070            3.6244        222.78                             44.56
33015    Incision of heart sac                            C
33020    Incision of heart sac                            C
33025    Incision of heart sac                            C
33030    Partial removal of heart sac                     C
33031    Partial removal of heart sac                     C
33050    Removal of heart sac lesion                      C
33120    Removal of heart lesion                          C
33130    Removal of heart lesion                          C
33140    Heart revascularize (tmr)                        C
33141    Heart tmr w/other procedure                      C
33200    Insertion of heart pacemaker             CH      D
33201    Insertion of heart pacemaker             CH      D
33202    Insert epicard eltrd, open               NI      C
33203    Insert epicard eltrd, endo               NI      C
33206    Insertion of heart pacemaker                     T      0089     123.6693             7601.7            1682.28        1520.34
33207    Insertion of heart pacemaker                     T      0089     123.6693             7601.7            1682.28        1520.34
33208    Insertion of heart pacemaker                     T      0655     152.6392            9382.43                           1876.49
33210    Insertion of heart electrode                     T      0106      58.8594            3617.97                            723.59
33211    Insertion of heart electrode                     T      0106      58.8594            3617.97                            723.59
33212    Insertion of pulse generator                     T      0090      98.3023            6042.45             1612.8        1208.49
33213    Insertion of pulse generator                     T      0654     112.7719            6931.86                           1386.37
33214    Upgrade of pacemaker system                      T      0655     152.6392            9382.43                           1876.49
33215    Reposition pacing-defib lead                     T      0105      25.6142            1574.45              370.4         314.89
33216    Insert lead pace-defib, one                      T      0106      58.8594            3617.97                            723.59
33217    Insert lead pace-defib, dual                     T      0106      58.8594            3617.97                            723.59
33218    Repair lead pace-defib, one              CH      T      0105      25.6142            1574.45              370.4         314.89
33220    Repair lead pace-defib, dual             CH      T      0105      25.6142            1574.45              370.4         314.89
33222    Revise pocket, pacemaker                         T      0027
                                                                   Milliman21.4302            1317.27             329.72         263.45
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 32 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
33223    Revise pocket, pacing-defib                      T      0027           21.4302       1317.27       329.72     263.45
33224    Insert pacing lead & connect                     T      0418          307.2828      18888.06                 3777.61
33225    Lventric pacing lead add-on                      T      0418          307.2828      18888.06                 3777.61
33226    Reposition l ventric lead                        T      0105           25.6142       1574.45        370.4     314.89
33233    Removal of pacemaker system                      T      0105           25.6142       1574.45        370.4     314.89
33234    Removal of pacemaker system                      T      0105           25.6142       1574.45        370.4     314.89
33235    Removal pacemaker electrode                      T      0105           25.6142       1574.45        370.4     314.89
33236    Remove electrode/thoracotomy                     C
33237    Remove electrode/thoracotomy                     C
33238    Remove electrode/thoracotomy                     C
33240    Insert pulse generator                           B
33241    Remove pulse generator                           T      0105           25.6142       1574.45            370.4         314.89
33243    Remove eltrd/thoracotomy                         C
33244    Remove eltrd, transven                           T      0105           25.6142       1574.45            370.4         314.89
33245    Insert epic eltrd pace-defib             CH      D
33246    Insert epic eltrd/generator              CH      D
33249    Eltrd/insert pace-defib                          B
33250    Ablate heart dysrhythm focus                     C
33251    Ablate heart dysrhythm focus                     C
33253    Reconstruct atria                        CH      D
33254    Ablate atria, lmtd                       NI      C
33255    Ablate atria w/o bypass, ext             NI      C
33256    Ablate atria w/bypass, exten             NI      C
33261    Ablate heart dysrhythm focus                     C
33265    Ablate atria w/bypass, endo              NI      C
33266    Ablate atria w/o bypass endo             NI      C
33282    Implant pat-active ht record                     S      0680           72.6022       4462.71                          892.54
33284    Remove pat-active ht record                      T      0109           10.9918        675.64                          135.13
33300    Repair of heart wound                            C
33305    Repair of heart wound                            C
33310    Exploratory heart surgery                        C
33315    Exploratory heart surgery                        C
33320    Repair major blood vessel(s)                     C
33321    Repair major vessel                              C
33322    Repair major blood vessel(s)                     C
33330    Insert major vessel graft                        C
33332    Insert major vessel graft                        C
33335    Insert major vessel graft                        C
33400    Repair of aortic valve                           C
33401    Valvuloplasty, open                              C
33403    Valvuloplasty, w/cp bypass                       C
33404    Prepare heart-aorta conduit                      C
33405    Replacement of aortic valve                      C
33406    Replacement of aortic valve                      C
33410    Replacement of aortic valve                      C
33411    Replacement of aortic valve                      C
33412    Replacement of aortic valve                      C
33413    Replacement of aortic valve                      C
33414    Repair of aortic valve                           C
33415    Revision, subvalvular tissue                     C
33416    Revise ventricle muscle                          C
33417    Repair of aortic valve                           C
33420    Revision of mitral valve                         C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 33 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
33422    Revision of mitral valve                         C
33425    Repair of mitral valve                           C
33426    Repair of mitral valve                           C
33427    Repair of mitral valve                           C
33430    Replacement of mitral valve                      C
33460    Revision of tricuspid valve                      C
33463    Valvuloplasty, tricuspid                         C
33464    Valvuloplasty, tricuspid                         C
33465    Replace tricuspid valve                          C
33468    Revision of tricuspid valve                      C
33470    Revision of pulmonary valve                      C
33471    Valvotomy, pulmonary valve                       C
33472    Revision of pulmonary valve                      C
33474    Revision of pulmonary valve                      C
33475    Replacement, pulmonary valve                     C
33476    Revision of heart chamber                        C
33478    Revision of heart chamber                        C
33496    Repair, prosth valve clot                        C
33500    Repair heart vessel fistula                      C
33501    Repair heart vessel fistula                      C
33502    Coronary artery correction                       C
33503    Coronary artery graft                            C
33504    Coronary artery graft                            C
33505    Repair artery w/tunnel                           C
33506    Repair artery, translocation                     C
33507    Repair art, intramural                           C
33508    Endoscopic vein harvest                          N
33510    CABG, vein, single                               C
33511    CABG, vein, two                                  C
33512    CABG, vein, three                                C
33513    CABG, vein, four                                 C
33514    CABG, vein, five                                 C
33516    Cabg, vein, six or more                          C
33517    CABG, artery-vein, single                        C
33518    CABG, artery-vein, two                           C
33519    CABG, artery-vein, three                         C
33521    CABG, artery-vein, four                          C
33522    CABG, artery-vein, five                          C
33523    Cabg, art-vein, six or more                      C
33530    Coronary artery, bypass/reop                     C
33533    CABG, arterial, single                           C
33534    CABG, arterial, two                              C
33535    CABG, arterial, three                            C
33536    Cabg, arterial, four or more                     C
33542    Removal of heart lesion                          C
33545    Repair of heart damage                           C
33548    Restore/remodel, ventricle                       C
33572    Open coronary endarterectomy                     C
33600    Closure of valve                                 C
33602    Closure of valve                                 C
33606    Anastomosis/artery-aorta                         C
33608    Repair anomaly w/conduit                         C
33610    Repair by enlargement                            C        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                  Page 34 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
33611    Repair double ventricle                          C
33612    Repair double ventricle                          C
33615    Repair, modified fontan                          C
33617    Repair single ventricle                          C
33619    Repair single ventricle                          C
33641    Repair heart septum defect                       C
33645    Revision of heart veins                          C
33647    Repair heart septum defects                      C
33660    Repair of heart defects                          C
33665    Repair of heart defects                          C
33670    Repair of heart chambers                         C
33675    Close mult vsd                           NI      C
33676    Close mult vsd w/resection               NI      C
33677    Cl mult vsd w/rem pul band               NI      C
33681    Repair heart septum defect                       C
33684    Repair heart septum defect                       C
33688    Repair heart septum defect                       C
33690    Reinforce pulmonary artery                       C
33692    Repair of heart defects                          C
33694    Repair of heart defects                          C
33697    Repair of heart defects                          C
33702    Repair of heart defects                          C
33710    Repair of heart defects                          C
33720    Repair of heart defect                           C
33722    Repair of heart defect                           C
33724    Repair venous anomaly                    NI      C
33726    Repair pul venous stenosis               NI      C
33730    Repair heart-vein defect(s)                      C
33732    Repair heart-vein defect                         C
33735    Revision of heart chamber                        C
33736    Revision of heart chamber                        C
33737    Revision of heart chamber                        C
33750    Major vessel shunt                               C
33755    Major vessel shunt                               C
33762    Major vessel shunt                               C
33764    Major vessel shunt & graft                       C
33766    Major vessel shunt                               C
33767    Major vessel shunt                               C
33768    Cavopulmonary shunting                           C
33770    Repair great vessels defect                      C
33771    Repair great vessels defect                      C
33774    Repair great vessels defect                      C
33775    Repair great vessels defect                      C
33776    Repair great vessels defect                      C
33777    Repair great vessels defect                      C
33778    Repair great vessels defect                      C
33779    Repair great vessels defect                      C
33780    Repair great vessels defect                      C
33781    Repair great vessels defect                      C
33786    Repair arterial trunk                            C
33788    Revision of pulmonary artery                     C
33800    Aortic suspension                                C
33802    Repair vessel defect                             C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                  Page 35 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
33803    Repair vessel defect                             C
33813    Repair septal defect                             C
33814    Repair septal defect                             C
33820    Revise major vessel                              C
33822    Revise major vessel                              C
33824    Revise major vessel                              C
33840    Remove aorta constriction                        C
33845    Remove aorta constriction                        C
33851    Remove aorta constriction                        C
33852    Repair septal defect                             C
33853    Repair septal defect                             C
33860    Ascending aortic graft                           C
33861    Ascending aortic graft                           C
33863    Ascending aortic graft                           C
33870    Transverse aortic arch graft                     C
33875    Thoracic aortic graft                            C
33877    Thoracoabdominal graft                           C
33880    Endovasc taa repr incl subcl                     C
33881    Endovasc taa repr w/o subcl                      C
33883    Insert endovasc prosth, taa                      C
33884    Endovasc prosth, taa, add-on                     C
33886    Endovasc prosth, delayed                         C
33889    Artery transpose/endovas taa                     C
33891    Car-car bp grft/endovas taa                      C
33910    Remove lung artery emboli                        C
33915    Remove lung artery emboli                        C
33916    Surgery of great vessel                          C
33917    Repair pulmonary artery                          C
33920    Repair pulmonary atresia                         C
33922    Transect pulmonary artery                        C
33924    Remove pulmonary shunt                           C
33925    Rpr pul art unifocal w/o cpb                     C
33926    Repr pul art, unifocal w/cpb                     C
33930    Removal of donor heart/lung                      C
33933    Prepare donor heart/lung                         C
33935    Transplantation, heart/lung                      C
33940    Removal of donor heart                           C
33944    Prepare donor heart                              C
33945    Transplantation of heart                         C
33960    External circulation assist                      C
33961    External circulation assist                      C
33967    Insert ia percut device                          C
33968    Remove aortic assist device                      C
33970    Aortic circulation assist                        C
33971    Aortic circulation assist                        C
33973    Insert balloon device                            C
33974    Remove intra-aortic balloon                      C
33975    Implant ventricular device                       C
33976    Implant ventricular device                       C
33977    Remove ventricular device                        C
33978    Remove ventricular device                        C
33979    Insert intracorporeal device                     C
33980    Remove intracorporeal device                     C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                  Page 36 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                    National             Minimum
HCPCS/                                                                         Relative            Unadjusted            Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment             Copayment
33999    Cardiac surgery procedure                        T      0070            3.6244    222.78                              44.56
34001    Removal of artery clot                           C
34051    Removal of artery clot                           C
34101    Removal of artery clot                           T      0088           37.7391     2319.75            655.22         463.95
34111    Removal of arm artery clot                       T      0088           37.7391     2319.75            655.22         463.95
34151    Removal of artery clot                           C
34201    Removal of artery clot                           T      0088           37.7391     2319.75            655.22         463.95
34203    Removal of leg artery clot                       T      0088           37.7391     2319.75            655.22         463.95
34401    Removal of vein clot                             C
34421    Removal of vein clot                             T      0088           37.7391     2319.75            655.22         463.95
34451    Removal of vein clot                             C
34471    Removal of vein clot                             T      0088           37.7391     2319.75            655.22         463.95
34490    Removal of vein clot                             T      0088           37.7391     2319.75            655.22         463.95
34501    Repair valve, femoral vein                       T      0088           37.7391     2319.75            655.22         463.95
34502    Reconstruct vena cava                            C
34510    Transposition of vein valve                      T      0088           37.7391     2319.75            655.22         463.95
34520    Cross-over vein graft                            T      0088           37.7391     2319.75            655.22         463.95
34530    Leg vein fusion                                  T      0088           37.7391     2319.75            655.22         463.95
34800    Endovas aaa repr w/sm tube                       C
34802    Endovas aaa repr w/2-p part                      C
34803    Endovas aaa repr w/3-p part                      C
34804    Endovas aaa repr w/1-p part                      C
34805    Endovas aaa repr w/long tube                     C
34808    Endovas iliac a device addon                     C
34812    Xpose for endoprosth, femorl                     C
34813    Femoral endovas graft add-on                     C
34820    Xpose for endoprosth, iliac                      C
34825    Endovasc extend prosth, init                     C
34826    Endovasc exten prosth, addÆl                     C
34830    Open aortic tube prosth repr                     C
34831    Open aortoiliac prosth repr                      C
34832    Open aortofemor prosth repr                      C
34833    Xpose for endoprosth, iliac                      C
34834    Xpose, endoprosth, brachial                      C
34900    Endovasc iliac repr w/graft                      C
35001    Repair defect of artery                          C
35002    Repair artery rupture, neck                      C
35005    Repair defect of artery                          C
35011    Repair defect of artery                          T      0653           32.3818   $1,990.44                         $398.09
35013    Repair artery rupture, arm                       C
35021    Repair defect of artery                          C
35022    Repair artery rupture, chest                     C
35045    Repair defect of arm artery                      C
35081    Repair defect of artery                          C
35082    Repair artery rupture, aorta                     C
35091    Repair defect of artery                          C
35092    Repair artery rupture, aorta                     C
35102    Repair defect of artery                          C
35103    Repair artery rupture, groin                     C
35111    Repair defect of artery                          C
35112    Repair artery rupture,spleen                     C
35121    Repair defect of artery                          C
35122    Repair artery rupture, belly                     C        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
35131    Repair defect of artery                          C
35132    Repair artery rupture, groin                     C
35141    Repair defect of artery                          C
35142    Repair artery rupture, thigh                     C
35151    Repair defect of artery                          C
35152    Repair artery rupture, knee                      C
35180    Repair blood vessel lesion                       T      0093           22.8653       1405.48                                281.1
35182    Repair blood vessel lesion                       C
35184    Repair blood vessel lesion                       T      0093           22.8653       1405.48                            281.1
35188    Repair blood vessel lesion                       T      0088           37.7391       2319.75            655.22         463.95
35189    Repair blood vessel lesion                       C
35190    Repair blood vessel lesion                       T      0093           22.8653       1405.48                            281.1
35201    Repair blood vessel lesion                       T      0093           22.8653       1405.48                            281.1
35206    Repair blood vessel lesion                       T      0093           22.8653       1405.48                            281.1
35207    Repair blood vessel lesion                       T      0088           37.7391       2319.75            655.22         463.95
35211    Repair blood vessel lesion                       C
35216    Repair blood vessel lesion                       C
35221    Repair blood vessel lesion                       C
35226    Repair blood vessel lesion                       T      0093           22.8653       1405.48                                281.1
35231    Repair blood vessel lesion                       T      0093           22.8653       1405.48                                281.1
35236    Repair blood vessel lesion                       T      0093           22.8653       1405.48                                281.1
35241    Repair blood vessel lesion                       C
35246    Repair blood vessel lesion                       C
35251    Repair blood vessel lesion                       C
35256    Repair blood vessel lesion                       T      0093           22.8653       1405.48                            281.1
35261    Repair blood vessel lesion                       T      0653           32.3818       1990.44                           398.09
35266    Repair blood vessel lesion                       T      0653           32.3818       1990.44                           398.09
35271    Repair blood vessel lesion                       C
35276    Repair blood vessel lesion                       C
35281    Repair blood vessel lesion                       C
35286    Repair blood vessel lesion                       T      0653           32.3818       1990.44                           398.09
35301    Rechanneling of artery                           C
35302    Rechanneling of artery                   NI      C
35303    Rechanneling of artery                   NI      C
35304    Rechanneling of artery                   NI      C
35305    Rechanneling of artery                   NI      C
35306    Rechanneling of artery                   NI      C
35311    Rechanneling of artery                           C
35321    Rechanneling of artery                           T      0093           22.8653       1405.48                                281.1
35331    Rechanneling of artery                           C
35341    Rechanneling of artery                           C
35351    Rechanneling of artery                           C
35355    Rechanneling of artery                           C
35361    Rechanneling of artery                           C
35363    Rechanneling of artery                           C
35371    Rechanneling of artery                           C
35372    Rechanneling of artery                           C
35381    Rechanneling of artery                   CH      D
35390    Reoperation, carotid add-on                      C
35400    Angioscopy                                       C
35450    Repair arterial blockage                         C
35452    Repair arterial blockage                         C
35454    Repair arterial blockage                         C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 38 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468      2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
35456    Repair arterial blockage                         C
35458    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35459    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35460    Repair venous blockage                           T      0081           42.9360       2639.19                     527.84
35470    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35471    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35472    Repair arterial blockage                         T      0081           42.9360     $2,639.19                   $527.84
35473    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35474    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35475    Repair arterial blockage                         T      0081           42.9360       2639.19                     527.84
35476    Repair venous blockage                           T      0081           42.9360     $2,639.19                   $527.84
35480    Atherectomy, open                                C
35481    Atherectomy, open                                C
35482    Atherectomy, open                                C
35483    Atherectomy, open                                C
35484    Atherectomy, open                                T      0081           42.9360     $2,639.19                   $527.84
35485    Atherectomy, open                                T      0081           42.9360       2639.19                     527.84
35490    Atherectomy, percutaneous                        T      0081           42.9360     $2,639.19                   $527.84
35491    Atherectomy, percutaneous                        T      0081           42.9360       2639.19                     527.84
35492    Atherectomy, percutaneous                        T      0081           42.9360       2639.19                     527.84
35493    Atherectomy, percutaneous                        T      0081           42.9360       2639.19                     527.84
35494    Atherectomy, percutaneous                        T      0081           42.9360     $2,639.19                   $527.84
35495    Atherectomy, percutaneous                        T      0081           42.9360       2639.19                     527.84
35500    Harvest vein for bypass                          T      0081           42.9360       2639.19                     527.84
35501    Artery bypass graft                              C
35506    Artery bypass graft                              C
35507    Artery bypass graft                      CH      D
35508    Artery bypass graft                              C
35509    Artery bypass graft                              C
35510    Artery bypass graft                              C
35511    Artery bypass graft                              C
35512    Artery bypass graft                              C
35515    Artery bypass graft                              C
35516    Artery bypass graft                              C
35518    Artery bypass graft                              C
35521    Artery bypass graft                              C
35522    Artery bypass graft                              C
35525    Artery bypass graft                              C
35526    Artery bypass graft                              C
35531    Artery bypass graft                              C
35533    Artery bypass graft                              C
35536    Artery bypass graft                              C
35537    Artery bypass graft                      NI      C
35538    Artery bypass graft                      NI      C
35539    Artery bypass graft                      NI      C
35540    Artery bypass graft                      NI      C
35541    Artery bypass graft                      CH      D
35546    Artery bypass graft                      CH      D
35548    Artery bypass graft                              C
35549    Artery bypass graft                              C
35551    Artery bypass graft                              C
35556    Artery bypass graft                              C
35558    Artery bypass graft                              C        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                  Page 39 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468         2007 CF
                                                                                                        National        Minimum
HCPCS/                                                                         Relative                Unadjusted       Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment        Copayment
35560    Artery bypass graft                              C
35563    Artery bypass graft                              C
35565    Artery bypass graft                              C
35566    Artery bypass graft                              C
35571    Artery bypass graft                              C
35572    Harvest femoropopliteal vein                     N
35583    Vein bypass graft                                C
35585    Vein bypass graft                                C
35587    Vein bypass graft                                C
35600    Harvest artery for cabg                          C
35601    Artery bypass graft                              C
35606    Artery bypass graft                              C
35612    Artery bypass graft                              C
35616    Artery bypass graft                              C
35621    Artery bypass graft                              C
35623    Bypass graft, not vein                           C
35626    Artery bypass graft                              C
35631    Artery bypass graft                              C
35636    Artery bypass graft                              C
35637    Artery bypass graft                      NI      C
35638    Artery bypass graft                      NI      C
35641    Artery bypass graft                      CH      D
35642    Artery bypass graft                              C
35645    Artery bypass graft                              C
35646    Artery bypass graft                              C
35647    Artery bypass graft                              C
35650    Artery bypass graft                              C
35651    Artery bypass graft                              C
35654    Artery bypass graft                              C
35656    Artery bypass graft                              C
35661    Artery bypass graft                              C
35663    Artery bypass graft                              C
35665    Artery bypass graft                              C
35666    Artery bypass graft                              C
35671    Artery bypass graft                              C
35681    Composite bypass graft                           C
35682    Composite bypass graft                           C
35683    Composite bypass graft                           C
35685    Bypass graft patency/patch                       T      0093           22.8653       1405.48                             281.1
35686    Bypass graft/av fist patency                     T      0093           22.8653       1405.48                             281.1
35691    Arterial transposition                           C
35693    Arterial transposition                           C
35694    Arterial transposition                           C
35695    Arterial transposition                           C
35697    Reimplant artery each                            C
35700    Reoperation, bypass graft                        C
35701    Exploration, carotid artery                      C
35721    Exploration, femoral artery                      C
35741    Exploration popliteal artery                     C
35761    Exploration of artery/vein                       T      0115           29.2133     $1,795.68        $374.81       $359.14
35800    Explore neck vessels                             C
35820    Explore chest vessels                            C
35840    Explore abdominal vessels                        C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 40 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                    National             Minimum
HCPCS/                                                                         Relative            Unadjusted            Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment             Copayment
35860    Explore limb vessels                             T      0093           22.8653 $1,405.48                           $281.10
35870    Repair vessel graft defect                       C
35875    Removal of clot in graft                         T      0088           37.7391   $2,319.75        $655.22          $463.95
35876    Removal of clot in graft                         T      0088           37.7391   $2,319.75        $655.22          $463.95
35879    Revise graft w/vein                              T      0088           37.7391   $2,319.75        $655.22          $463.95
35881    Revise graft w/vein                              T      0088           37.7391   $2,319.75        $655.22          $463.95
35883    Revise graft w/nonauto graft             NI      T      0088           37.7391   $2,319.75        $655.22          $463.95
35884    Revise graft w/vein                      NI      T      0088           37.7391   $2,319.75        $655.22          $463.95
35901    Excision, graft, neck                            C
35903    Excision, graft, extremity                       T      0115           29.2133     1795.68            374.81         359.14
35905    Excision, graft, thorax                          C
35907    Excision, graft, abdomen                         C
36000    Place needle in vein                             N
36002    Pseudoaneurysm injection trt                     S      0267            2.4606      151.25              60.5              30.25
36005    Injection ext venography                         N
36010    Place catheter in vein                           N
36011    Place catheter in vein                           N
36012    Place catheter in vein                           N
36013    Place catheter in artery                         N
36014    Place catheter in artery                         N
36015    Place catheter in artery                         N
36100    Establish access to artery                       N
36120    Establish access to artery                       N
36140    Establish access to artery                       N
36145    Artery to vein shunt                             N
36160    Establish access to aorta                        N
36200    Place catheter in aorta                          N
36215    Place catheter in artery                         N
36216    Place catheter in artery                         N
36217    Place catheter in artery                         N
36218    Place catheter in artery                         N
36245    Place catheter in artery                         N
36246    Place catheter in artery                         N
36247    Place catheter in artery                         N
36248    Place catheter in artery                         N
36260    Insertion of infusion pump                       T      0623           28.5032   $1,752.03                         $350.41
36261    Revision of infusion pump                        T      0623           28.5032   $1,752.03                         $350.41
36262    Removal of infusion pump                         T      0622           22.6665   $1,393.26                         $278.65
36299    Vessel injection procedure                       N
36400    Bl draw < 3 yrs fem/jugular                      N
36405    Bl draw < 3 yrs scalp vein                       N
36406    Bl draw < 3 yrs other vein                       N
36410    Non-routine bl draw > 3 yrs                      N
36415    Routine venipuncture                             A
36416    Capillary blood draw                             N
36420    Vein access cutdown < 1 yr                       T      0035       0.1999          $12.29                             $2.46
36425    Vein access cutdown > 1 yr                       T      0035       0.1999          $12.29                             $2.46
36430    Blood transfusion service                        S      0110       3.4584         $212.58                            $42.52
36440    Bl push transfuse, 2 yr or <                     S      0110       3.4584         $212.58                            $42.52
36450    Bl exchange/transfuse, nb                        S      0110       3.4584         $212.58                            $42.52
36455    Bl exchange/transfuse non-nb                     S      0110       3.4584         $212.58                            $42.52
36460    Transfusion service, fetal                       S      0110       3.4584           212.58                             42.52
36468    Injection(s), spider veins                       T        Milliman 1.0798
                                                                 0098                       $66.37                            $13.27
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 41 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468          2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
36469    Injection(s), spider veins                       T      0098            1.0798        $66.37                         $13.27
36470    Injection therapy of vein                        T      0098            1.0798          66.37                          13.27
36471    Injection therapy of veins                       T      0098            1.0798          66.37                          13.27
36475    Endovenous rf, 1st vein                          T      0091           34.7288       2134.71                          426.94
36476    Endovenous rf, vein add-on                       T      0091           34.7288       2134.71                          426.94
36478    Endovenous laser, 1st vein               CH      T      0092           24.8809     $1,529.38     $309.87            $305.88
36479    Endovenous laser vein addon              CH      T      0092           24.8809     $1,529.38     $309.87            $305.88
36481    Insertion of catheter, vein                      N
36500    Insertion of catheter, vein                      N
36510    Insertion of catheter, vein                      N
36511    Apheresis wbc                                    S      0111           11.7134       $720.00         $198.40         $144.00
36512    Apheresis rbc                                    S      0111           11.7134            720           198.4             144
36513    Apheresis platelets                              S      0111           11.7134            720           198.4             144
36514    Apheresis plasma                                 S      0111           11.7134            720           198.4             144
36515    Apheresis, adsorp/reinfuse                       S      0112           30.2231        1857.75          433.29          371.55
36516    Apheresis, selective                             S      0112           30.2231        1857.75          433.29          371.55
36522    Photopheresis                                    S      0112           30.2231        1857.75          433.29          371.55
36540    Collect blood venous device              CH      Q      0624            0.5145          31.63           12.65            6.33
36550    Declot vascular device                           T      0676            2.0726          127.4                           25.48
36555    Insert non-tunnel cv cath                        T      0621            8.7846         539.97                          107.99
36556    Insert non-tunnel cv cath                        T      0621            8.7846       $539.97                         $107.99
36557    Insert tunneled cv cath                          T      0622           22.6665     $1,393.26                         $278.65
36558    Insert tunneled cv cath                          T      0622           22.6665     $1,393.26                         $278.65
36560    Insert tunneled cv cath                          T      0623           28.5032     $1,752.03                         $350.41
36561    Insert tunneled cv cath                          T      0623           28.5032     $1,752.03                         $350.41
36563    Insert tunneled cv cath                          T      0623           28.5032     $1,752.03                         $350.41
36565    Insert tunneled cv cath                          T      0623           28.5032     $1,752.03                         $350.41
36566    Insert tunneled cv cath                  CH      T      0625           83.4609     $5,130.17                       $1,026.03
36568    Insert picc cath                                 T      0621            8.7846       $539.97                         $107.99
36569    Insert picc cath                                 T      0621            8.7846       $539.97                         $107.99
36570    Insert picvad cath                               T      0622           22.6665        1393.26                          278.65
36571    Insert picvad cath                               T      0622           22.6665        1393.26                          278.65
36575    Repair tunneled cv cath                          T      0621            8.7846         539.97                          107.99
36576    Repair tunneled cv cath                          T      0621            8.7846       $539.97                         $107.99
36578    Replace tunneled cv cath                         T      0622           22.6665     $1,393.26                         $278.65
36580    Replace cvad cath                                T      0621            8.7846       $539.97                         $107.99
36581    Replace tunneled cv cath                         T      0622           22.6665     $1,393.26                         $278.65
36582    Replace tunneled cv cath                         T      0623           28.5032     $1,752.03                         $350.41
36583    Replace tunneled cv cath                         T      0623           28.5032     $1,752.03                         $350.41
36584    Replace picc cath                                T      0621            8.7846       $539.97                         $107.99
36585    Replace picvad cath                              T      0622           22.6665     $1,393.26                         $278.65
36589    Removal tunneled cv cath                         T      0621            8.7846       $539.97                         $107.99
36590    Removal tunneled cv cath                         T      0621            8.7846         539.97                          107.99
36595    Mech remov tunneled cv cath                      T      0622           22.6665        1393.26                          278.65
36596    Mech remov tunneled cv cath                      T      0621            8.7846       $539.97                         $107.99
36597    Reposition venous catheter                       T      0621            8.7846       $539.97                         $107.99
36598    Inj w/fluor, eval cv device                      X      0340            0.6102        $37.51                           $7.50
36600    Withdrawal of arterial blood             CH      Q      0035            0.1999        $12.29                           $2.46
36620    Insertion catheter, artery                       N
36625    Insertion catheter, artery                       N
36640    Insertion catheter, artery                       T      0623           28.5032       1752.03                          350.41
36660    Insertion catheter, artery                       C
36680    Insert needle, bone cavity                       T        Milliman 1.0995
                                                                 0002                          $67.58                          $13.52
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 42 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                         National   Minimum
HCPCS/                                                                         Relative                 Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate      Copayment Copayment
36800    Insertion of cannula                             T      0115           29.2133   1795.68            374.81     359.14
36810    Insertion of cannula                             T      0115           29.2133   1795.68            374.81     359.14
36815    Insertion of cannula                             T      0115           29.2133 $1,795.68            374.81   $359.14
36818    Av fuse, uppr arm, cephalic                      T      0088           37.7391   2319.75            655.22     463.95
36819    Av fuse, uppr arm, basilic                       T      0088           37.7391   2319.75            655.22     463.95
36820    Av fusion/forearm vein                           T      0088           37.7391   2319.75            655.22     463.95
36821    Av fusion direct any site                        T      0088           37.7391   2319.75            655.22     463.95
36822    Insertion of cannula(s)                          C
36823    Insertion of cannula(s)                          C
36825    Artery-vein autograft                            T      0088           37.7391   $2,319.75           655.22         $463.95
36830    Artery-vein nonautograft                         T      0088           37.7391     2319.75           655.22           463.95
36831    Open thrombect av fistula                        T      0088           37.7391     2319.75           655.22           463.95
36832    Av fistula revision, open                        T      0088           37.7391     2319.75           655.22           463.95
36833    Av fistula revision                              T      0088           37.7391     2319.75           655.22           463.95
36834    Repair A-V aneurysm                              T      0088           37.7391   $2,319.75         $655.22          $463.95
36835    Artery to vein shunt                             T      0115           29.2133     1795.68           374.81           359.14
36838    Dist revas ligation, hemo                        T      0088           37.7391     2319.75           655.22           463.95
36860    External cannula declotting                      T      0676            2.0726        127.4                            25.48
36861    Cannula declotting                               T      0115           29.2133     1795.68             374.81         359.14
36870    Percut thrombect av fistula                      T      0653           32.3818     1990.44                            398.09
37140    Revision of circulation                          C
37145    Revision of circulation                          C
37160    Revision of circulation                          C
37180    Revision of circulation                          C
37181    Splice spleen/kidney veins                       C
37182    Insert hepatic shunt (tips)                      C
37183    Remove hepatic shunt (tips)                      T      0229           68.4697       4208.7                           841.74
37184    Prim art mech thrombectomy               CH      T      0088           37.7391      2319.75          655.22           463.95
37185    Prim art m-thrombect add-on              CH      T      0088           37.7391   $2,319.75           655.22         $463.95
37186    Sec art m-thrombect add-on               CH      T      0088           37.7391   $2,319.75         $655.22          $463.95
37187    Venous mech thrombectomy                 CH      T      0088           37.7391   $2,319.75         $655.22          $463.95
37188    Venous m-thrombectomy add-on             CH      T      0088           37.7391   $2,319.75         $655.22          $463.95
37195    Thrombolytic therapy, stroke                     T      0676            2.0726     $127.40                           $25.48
37200    Transcatheter biopsy                             T      0685            6.1384     $377.32         $115.47           $75.46
37201    Transcatheter therapy infuse                     T      0676            2.0726     $127.40                           $25.48
37202    Transcatheter therapy infuse                     T      0676            2.0726     $127.40                           $25.48
37203    Transcatheter retrieval                          T      0103           16.2375     $998.09         $223.63          $199.62
37204    Transcatheter occlusion                          T      0115           29.2133   $1,795.68         $374.81          $359.14
37205    Transcath iv stent, percut                       T      0229           68.4697   $4,208.70                          $841.74
37206    Transcath iv stent/perc addl                     T      0229           68.4697   $4,208.70                          $841.74
37207    Transcath iv stent, open                         T      0229           68.4697   $4,208.70                          $841.74
37208    Transcath iv stent/open addl                     T      0229           68.4697   $4,208.70                          $841.74
37209    Change iv cath at thromb tx                      T      0103           16.2375     $998.09           223.63         $199.62
37210    Embolization uterine fibroid             NI      T      0202           42.9896   $2,642.48         $981.50          $528.50
37215    Transcath stent, cca w/eps                       C
37216    Transcath stent, cca w/o eps                     E
37250    Iv us first vessel add-on                        S      0416     32.5472         $2,000.61                          $400.12
37251    Iv us each add vessel add-on                     S      0416     32.5472         $2,000.61                          $400.12
37500    Endoscopy ligate perf veins              CH      T      0091     34.7288         $2,134.71                          $426.94
37501    Vascular endoscopy procedure                     T      0092     24.8809         $1,529.38             309.87       $305.88
37565    Ligation of neck vein                            T      0093     22.8653         $1,405.48                          $281.10
37600    Ligation of neck artery                          T      0093     22.8653         $1,405.48                          $281.10
37605    Ligation of neck artery                          T      0091     34.7288
                                                                   Milliman               $2,134.71                          $426.94
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 43 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
37606    Ligation of neck artery                  CH      T      0092           24.8809     $1,529.38     $309.87    $305.88
37607    Ligation of a-v fistula                          T      0092           24.8809     $1,529.38       309.87   $305.88
37609    Temporal artery procedure                        T      0021           15.1024       $928.31     $219.48    $185.66
37615    Ligation of neck artery                  CH      T      0092           24.8809     $1,529.38     $309.87    $305.88
37616    Ligation of chest artery                         C
37617    Ligation of abdomen artery                       C
37618    Ligation of extremity artery                     C
37620    Revision of major vein                           T      0091           34.7288     $2,134.71                        $426.94
37650    Revision of major vein                   CH      T      0092           24.8809     $1,529.38        $309.87         $305.88
37660    Revision of major vein                           C
37700    Revise leg vein                                  T      0091           34.7288     $2,134.71                        $426.94
37718    Ligate/strip short leg vein              CH      T      0091           34.7288     $2,134.71                        $426.94
37722    Ligate/strip long leg vein               CH      T      0091           34.7288     $2,134.71                        $426.94
37735    Removal of leg veins/lesion              CH      T      0091           34.7288     $2,134.71                        $426.94
37760    Ligation, leg veins, open                CH      T      0092           24.8809     $1,529.38        $309.87         $305.88
37765    Phleb veins - extrem - to 20             CH      T      0092           24.8809     $1,529.38        $309.87         $305.88
37766    Phleb veins - extrem 20+                 CH      T      0092           24.8809     $1,529.38        $309.87         $305.88
37780    Revision of leg vein                     CH      T      0092           24.8809     $1,529.38          309.87        $305.88
37785    Ligate/divide/excise vein                CH      T      0092           24.8809     $1,529.38        $309.87         $305.88
37788    Revascularization, penis                         C
37790    Penile venous occlusion                          T      0181           32.9873     $2,027.66        $621.82         $405.53
37799    Vascular surgery procedure                       T      0103           16.2375       $998.09        $223.63         $199.62
38100    Removal of spleen, total                         C
38101    Removal of spleen, partial                       C
38102    Removal of spleen, total                         C
38115    Repair of ruptured spleen                        C
38120    Laparoscopy, splenectomy                         T      0131           43.5488     $2,676.86      $1,001.89         $535.37
38129    Laparoscope proc, spleen                         T      0130           32.1241     $1,974.60        $659.53         $394.92
38200    Injection for spleen x-ray                       N
38204    Bl donor search management                       N
38205    Harvest allogenic stem cells                     S      0111           11.7134      $720.00         $198.40         $144.00
38206    Harvest auto stem cells                          S      0111           11.7134      $720.00         $198.40         $144.00
38207    Cryopreserve stem cells                          E
38208    Thaw preserved stem cells                        E
38209    Wash harvest stem cells                          E
38210    T-cell depletion of harvest                      E
38211    Tumor cell deplete of harvst                     E
38212    Rbc depletion of harvest                         E
38213    Platelet deplete of harvest                      E
38214    Volume deplete of harvest                        E
38215    Harvest stem cell concentrte                     E
38220    Bone marrow aspiration                           T      0003            2.4011       $147.59                         $29.52
38221    Bone marrow biopsy                               T      0003            2.4011       $147.59                         $29.52
38230    Bone marrow collection                           S      0123           20.3582     $1,251.38                        $250.28
38240    Bone marrow/stem transplant                      S      0123           20.3582     $1,251.38                        $250.28
38241    Bone marrow/stem transplant                      S      0123           20.3582     $1,251.38                        $250.28
38242    Lymphocyte infuse transplant                     S      0111           11.7134       $720.00            198.4       $144.00
38300    Drainage, lymph node lesion                      T      0007           11.1535       $685.58                        $137.12
38305    Drainage, lymph node lesion                      T      0008           17.5086     $1,076.22                        $215.24
38308    Incision of lymph channels                       T      0113           21.2621     $1,306.94                        $261.39
38380    Thoracic duct procedure                          C
38381    Thoracic duct procedure                          C
38382    Thoracic duct procedure                          C        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 44 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment            Copayment
38500    Biopsy/removal, lymph nodes                      T      0113           21.2621     $1,306.94                          $261.39
38505    Needle biopsy, lymph nodes                       T      0005            3.9045       $240.00      $71.59               $48.00
38510    Biopsy/removal, lymph nodes                      T      0113           21.2621     $1,306.94                          $261.39
38520    Biopsy/removal, lymph nodes                      T      0113           21.2621     $1,306.94                          $261.39
38525    Biopsy/removal, lymph nodes                      T      0113           21.2621     $1,306.94                          $261.39
38530    Biopsy/removal, lymph nodes                      T      0113           21.2621     $1,306.94                          $261.39
38542    Explore deep node(s), neck                       T      0114           37.7224     $2,318.72     $467.95              $463.74
38550    Removal, neck/armpit lesion                      T      0113           21.2621     $1,306.94                          $261.39
38555    Removal, neck/armpit lesion                      T      0113           21.2621     $1,306.94                          $261.39
38562    Removal, pelvic lymph nodes                      C
38564    Removal, abdomen lymph nodes                     C
38570    Laparoscopy, lymph node biop                     T      0131           43.5488     $2,676.86          1001.89         $535.37
38571    Laparoscopy, lymphadenectomy                     T      0132           70.5066     $4,333.90       $1,239.22          $866.78
38572    Laparoscopy, lymphadenectomy                     T      0131           43.5488     $2,676.86       $1,001.89          $535.37
38589    Laparoscope proc, lymphatic                      T      0130           32.1241     $1,974.60         $659.53          $394.92
38700    Removal of lymph nodes, neck                     T      0113           21.2621     $1,306.94                          $261.39
38720    Removal of lymph nodes, neck                     T      0113           21.2621     $1,306.94                          $261.39
38724    Removal of lymph nodes, neck                     C
38740    Remove armpit lymph nodes                        T      0114           37.7224     $2,318.72         $467.95          $463.74
38745    Remove armpit lymph nodes                        T      0114           37.7224     $2,318.72         $467.95          $463.74
38746    Remove thoracic lymph nodes                      C
38747    Remove abdominal lymph nodes                     C
38760    Remove groin lymph nodes                         T      0113           21.2621     $1,306.94                          $261.39
38765    Remove groin lymph nodes                         C
38770    Remove pelvis lymph nodes                        C
38780    Remove abdomen lymph nodes                       C
38790    Inject for lymphatic x-ray                       N
38792    Identify sentinel node                   CH      Q      0389            1.3754        $84.54              33.81         $16.91
38794    Access thoracic lymph duct                       N
38999    Blood/lymph system procedure                     S      0110            3.4584      $212.58                             $42.52
39000    Exploration of chest                             C
39010    Exploration of chest                             C
39200    Removal chest lesion                             C
39220    Removal chest lesion                             C
39400    Visualization of chest                           T      0069           31.9442     $1,963.55             591.64       $392.71
39499    Chest procedure                                  C
39501    Repair diaphragm laceration                      C
39502    Repair paraesophageal hernia                     C
39503    Repair of diaphragm hernia                       C
39520    Repair of diaphragm hernia                       C
39530    Repair of diaphragm hernia                       C
39531    Repair of diaphragm hernia                       C
39540    Repair of diaphragm hernia                       C
39541    Repair of diaphragm hernia                       C
39545    Revision of diaphragm                            C
39560    Resect diaphragm, simple                         C
39561    Resect diaphragm, complex                        C
39599    Diaphragm surgery procedure                      C
40490    Biopsy of lip                                    T      0251       2.4520            $150.72                           $30.14
40500    Partial excision of lip                          T      0253     16.4266           $1,009.71             282.29       $201.94
40510    Partial excision of lip                          T      0254     23.3299           $1,434.04             321.35       $286.81
40520    Partial excision of lip                          T      0253     16.4266           $1,009.71             282.29       $201.94
40525    Reconstruct lip with flap                        T      0254     23.3299
                                                                   Milliman                    1434.04            321.35         286.81
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
40527    Reconstruct lip with flap                        T      0254      23.3299     $1,434.04       321.35   $286.81
40530    Partial removal of lip                           T      0254      23.3299     $1,434.04     $321.35    $286.81
40650    Repair lip                                       T      0252       7.5511       $464.15     $109.16     $92.83
40652    Repair lip                                       T      0252       7.5511       $464.15       109.16    $92.83
40654    Repair lip                                       T      0252       7.5511       $464.15       109.16    $92.83
40700    Repair cleft lip/nasal                           T      0256      38.1991     $2,348.02                $469.60
40701    Repair cleft lip/nasal                           T      0256      38.1991     $2,348.02                $469.60
40702    Repair cleft lip/nasal                           T      0256      38.1991     $2,348.02                $469.60
40720    Repair cleft lip/nasal                           T      0256      38.1991        2348.02                  469.6
40761    Repair cleft lip/nasal                           T      0256      38.1991     $2,348.02                $469.60
40799    Lip surgery procedure                            T      0251       2.4520       $150.72                 $30.14
40800    Drainage of mouth lesion                 CH      T      0006       1.4392        $88.46                 $17.69
40801    Drainage of mouth lesion                         T      0252       7.5511       $464.15     $109.16     $92.83
40804    Removal, foreign body, mouth                     X      0340       0.6102        $37.51                  $7.50
40805    Removal, foreign body, mouth                     T      0252       7.5511       $464.15       109.16    $92.83
40806    Incision of lip fold                             T      0251       2.4520       $150.72                 $30.14
40808    Biopsy of mouth lesion                           T      0251       2.4520       $150.72                 $30.14
40810    Excision of mouth lesion                         T      0253      16.4266     $1,009.71     $282.29    $201.94
40812    Excise/repair mouth lesion                       T      0253      16.4266     $1,009.71     $282.29    $201.94
40814    Excise/repair mouth lesion                       T      0253      16.4266     $1,009.71     $282.29    $201.94
40816    Excision of mouth lesion                         T      0254      23.3299     $1,434.04     $321.35    $286.81
40818    Excise oral mucosa for graft                     T      0251       2.4520       $150.72                 $30.14
40819    Excise lip or cheek fold                         T      0252       7.5511       $464.15       109.16    $92.83
40820    Treatment of mouth lesion                        T      0253      16.4266     $1,009.71     $282.29    $201.94
40830    Repair mouth laceration                          T      0251       2.4520       $150.72                 $30.14
40831    Repair mouth laceration                          T      0252       7.5511       $464.15     $109.16     $92.83
40840    Reconstruction of mouth                          T      0254      23.3299     $1,434.04     $321.35    $286.81
40842    Reconstruction of mouth                          T      0254      23.3299     $1,434.04     $321.35    $286.81
40843    Reconstruction of mouth                          T      0254      23.3299     $1,434.04     $321.35    $286.81
40844    Reconstruction of mouth                          T      0256      38.1991     $2,348.02                $469.60
40845    Reconstruction of mouth                          T      0256      38.1991     $2,348.02                $469.60
40899    Mouth surgery procedure                          T      0251       2.4520       $150.72                 $30.14
41000    Drainage of mouth lesion                         T      0253      16.4266     $1,009.71     $282.29    $201.94
41005    Drainage of mouth lesion                         T      0251       2.4520       $150.72                 $30.14
41006    Drainage of mouth lesion                         T      0254      23.3299     $1,434.04       321.35   $286.81
41007    Drainage of mouth lesion                         T      0253      16.4266        1009.71      282.29     201.94
41008    Drainage of mouth lesion                         T      0253      16.4266     $1,009.71     $282.29    $201.94
41009    Drainage of mouth lesion                         T      0251       2.4520       $150.72                 $30.14
41010    Incision of tongue fold                          T      0252       7.5511       $464.15       109.16    $92.83
41015    Drainage of mouth lesion                         T      0251       2.4520       $150.72                 $30.14
41016    Drainage of mouth lesion                         T      0252       7.5511         464.15      109.16      92.83
41017    Drainage of mouth lesion                         T      0252       7.5511       $464.15     $109.16     $92.83
41018    Drainage of mouth lesion                         T      0252       7.5511       $464.15     $109.16     $92.83
41100    Biopsy of tongue                                 T      0252       7.5511         464.15      109.16      92.83
41105    Biopsy of tongue                                 T      0253      16.4266     $1,009.71     $282.29    $201.94
41108    Biopsy of floor of mouth                         T      0252       7.5511       $464.15     $109.16     $92.83
41110    Excision of tongue lesion                        T      0253      16.4266        1009.71      282.29     201.94
41112    Excision of tongue lesion                        T      0253      16.4266     $1,009.71       282.29   $201.94
41113    Excision of tongue lesion                        T      0253      16.4266     $1,009.71     $282.29    $201.94
41114    Excision of tongue lesion                        T      0254      23.3299        1434.04      321.35     286.81
41115    Excision of tongue fold                          T      0252       7.5511       $464.15     $109.16     $92.83
41116    Excision of mouth lesion                         T      0253      16.4266     $1,009.71     $282.29    $201.94
41120    Partial removal of tongue                        T      0254
                                                                   Milliman23.3299     $1,434.04     $321.35    $286.81
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                          Page 46 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
41130    Partial removal of tongue                        C
41135    Tongue and neck surgery                          C
41140    Removal of tongue                                C
41145    Tongue removal, neck surgery                     C
41150    Tongue, mouth, jaw surgery                       C
41153    Tongue, mouth, neck surgery                      C
41155    Tongue, jaw, & neck surgery                      C
41250    Repair tongue laceration                         T      0251       2.4520              150.72                            30.14
41251    Repair tongue laceration                         T      0251       2.4520              150.72                            30.14
41252    Repair tongue laceration                         T      0252       7.5511              464.15            109.16          92.83
41500    Fixation of tongue                               T      0254     23.3299              1434.04            321.35         286.81
41510    Tongue to lip surgery                            T      0253     16.4266              1009.71            282.29         201.94
41520    Reconstruction, tongue fold                      T      0252       7.5511              464.15            109.16          92.83
41599    Tongue and mouth surgery                         T      0251       2.4520              150.72                            30.14
41800    Drainage of gum lesion                   CH      T      0006       1.4392               88.46                            17.69
41805    Removal foreign body, gum                        T      0254     23.3299           $1,434.04         $321.35          $286.81
41806    Removal foreign body,jawbone                     T      0253     16.4266              1009.71          282.29           201.94
41820    Excision, gum, each quadrant                     T      0252       7.5511            $464.15         $109.16           $92.83
41821    Excision of gum flap                             T      0252       7.5511            $464.15         $109.16           $92.83
41822    Excision of gum lesion                           T      0253     16.4266           $1,009.71         $282.29          $201.94
41823    Excision of gum lesion                           T      0254     23.3299           $1,434.04         $321.35          $286.81
41825    Excision of gum lesion                           T      0253     16.4266           $1,009.71         $282.29          $201.94
41826    Excision of gum lesion                           T      0253     16.4266           $1,009.71         $282.29          $201.94
41827    Excision of gum lesion                           T      0254     23.3299           $1,434.04         $321.35          $286.81
41828    Excision of gum lesion                           T      0253     16.4266           $1,009.71         $282.29          $201.94
41830    Removal of gum tissue                            T      0253     16.4266           $1,009.71         $282.29          $201.94
41850    Treatment of gum lesion                          T      0253     16.4266           $1,009.71         $282.29          $201.94
41870    Gum graft                                        T      0254     23.3299           $1,434.04         $321.35          $286.81
41872    Repair gum                                       T      0253     16.4266           $1,009.71         $282.29          $201.94
41874    Repair tooth socket                              T      0254     23.3299           $1,434.04         $321.35          $286.81
41899    Dental surgery procedure                         T      0251       2.4520            $150.72                           $30.14
42000    Drainage mouth roof lesion                       T      0251       2.4520            $150.72                           $30.14
42100    Biopsy roof of mouth                             T      0252       7.5511            $464.15         $109.16           $92.83
42104    Excision lesion, mouth roof                      T      0253     16.4266           $1,009.71         $282.29          $201.94
42106    Excision lesion, mouth roof                      T      0253     16.4266           $1,009.71         $282.29          $201.94
42107    Excision lesion, mouth roof                      T      0254     23.3299           $1,434.04         $321.35          $286.81
42120    Remove palate/lesion                             T      0256     38.1991           $2,348.02                          $469.60
42140    Excision of uvula                                T      0252       7.5511            $464.15         $109.16           $92.83
42145    Repair palate, pharynx/uvula                     T      0254     23.3299           $1,434.04         $321.35          $286.81
42160    Treatment mouth roof lesion                      T      0253     16.4266           $1,009.71         $282.29          $201.94
42180    Repair palate                                    T      0251       2.4520            $150.72                           $30.14
42182    Repair palate                                    T      0256     38.1991           $2,348.02                          $469.60
42200    Reconstruct cleft palate                         T      0256     38.1991           $2,348.02                          $469.60
42205    Reconstruct cleft palate                         T      0256     38.1991           $2,348.02                          $469.60
42210    Reconstruct cleft palate                         T      0256     38.1991           $2,348.02                          $469.60
42215    Reconstruct cleft palate                         T      0256     38.1991           $2,348.02                          $469.60
42220    Reconstruct cleft palate                         T      0256     38.1991           $2,348.02                          $469.60
42225    Reconstruct cleft palate                         T      0256     38.1991           $2,348.02                          $469.60
42226    Lengthening of palate                            T      0256     38.1991           $2,348.02                          $469.60
42227    Lengthening of palate                            T      0256     38.1991           $2,348.02                          $469.60
42235    Repair palate                                    T      0253     16.4266           $1,009.71         $282.29          $201.94
42260    Repair nose to lip fistula                       T      0254     23.3299           $1,434.04         $321.35          $286.81
42280    Preparation, palate mold                         T        Milliman 2.4520
                                                                 0251                         $150.72                           $30.14
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
42281    Insertion, palate prosthesis                     T      0253           16.4266     $1,009.71     $282.29    $201.94
42299    Palate/uvula surgery                             T      0251            2.4520       $150.72                 $30.14
42300    Drainage of salivary gland                       T      0253           16.4266     $1,009.71     $282.29    $201.94
42305    Drainage of salivary gland                       T      0253           16.4266     $1,009.71     $282.29    $201.94
42310    Drainage of salivary gland                       T      0251            2.4520       $150.72                 $30.14
42320    Drainage of salivary gland                       T      0251            2.4520       $150.72                 $30.14
42330    Removal of salivary stone                        T      0253           16.4266     $1,009.71     $282.29    $201.94
42335    Removal of salivary stone                        T      0253           16.4266     $1,009.71     $282.29    $201.94
42340    Removal of salivary stone                        T      0253           16.4266     $1,009.71     $282.29    $201.94
42400    Biopsy of salivary gland                         T      0005            3.9045       $240.00      $71.59     $48.00
42405    Biopsy of salivary gland                         T      0253           16.4266     $1,009.71     $282.29    $201.94
42408    Excision of salivary cyst                        T      0253           16.4266     $1,009.71     $282.29    $201.94
42409    Drainage of salivary cyst                        T      0253           16.4266        1009.71      282.29     201.94
42410    Excise parotid gland/lesion                      T      0256           38.1991        2348.02                  469.6
42415    Excise parotid gland/lesion                      T      0256           38.1991        2348.02                  469.6
42420    Excise parotid gland/lesion                      T      0256           38.1991        2348.02                  469.6
42425    Excise parotid gland/lesion                      T      0256           38.1991        2348.02                  469.6
42426    Excise parotid gland/lesion                      C
42440    Excise submaxillary gland                        T      0256           38.1991       2348.02                             469.6
42450    Excise sublingual gland                          T      0254           23.3299       1434.04             321.35         286.81
42500    Repair salivary duct                             T      0254           23.3299       1434.04             321.35         286.81
42505    Repair salivary duct                             T      0256           38.1991       2348.02                             469.6
42507    Parotid duct diversion                           T      0256           38.1991       2348.02                             469.6
42508    Parotid duct diversion                           T      0256           38.1991       2348.02                             469.6
42509    Parotid duct diversion                           T      0256           38.1991       2348.02                             469.6
42510    Parotid duct diversion                           T      0256           38.1991       2348.02                             469.6
42550    Injection for salivary x-ray                     N
42600    Closure of salivary fistula                      T      0253     16.4266             1009.71             282.29         201.94
42650    Dilation of salivary duct                        T      0252       7.5511              464.15            109.16          92.83
42660    Dilation of salivary duct                        T      0251       2.4520              150.72                            30.14
42665    Ligation of salivary duct                        T      0254     23.3299             1434.04             321.35         286.81
42699    Salivary surgery procedure                       T      0251       2.4520              150.72                            30.14
42700    Drainage of tonsil abscess                       T      0251       2.4520              150.72                            30.14
42720    Drainage of throat abscess                       T      0253     16.4266             1009.71             282.29         201.94
42725    Drainage of throat abscess                       T      0256     38.1991             2348.02                             469.6
42800    Biopsy of throat                         CH      T      0252       7.5511              464.15          109.16            92.83
42802    Biopsy of throat                                 T      0253     16.4266             1009.71           282.29           201.94
42804    Biopsy of upper nose/throat                      T      0253     16.4266             1009.71           282.29           201.94
42806    Biopsy of upper nose/throat                      T      0254     23.3299           $1,434.04         $321.35          $286.81
42808    Excise pharynx lesion                            T      0253     16.4266           $1,009.71         $282.29          $201.94
42809    Remove pharynx foreign body                      X      0340       0.6102             $37.51                            $7.50
42810    Excision of neck cyst                            T      0254     23.3299           $1,434.04         $321.35          $286.81
42815    Excision of neck cyst                            T      0256     38.1991             2348.02                             469.6
42820    Remove tonsils and adenoids                      T      0258     22.1165             1359.46           437.25           271.89
42821    Remove tonsils and adenoids                      T      0258     22.1165           $1,359.46         $437.25          $271.89
42825    Removal of tonsils                               T      0258     22.1165             1359.46           437.25           271.89
42826    Removal of tonsils                               T      0258     22.1165             1359.46           437.25           271.89
42830    Removal of adenoids                              T      0258     22.1165             1359.46           437.25           271.89
42831    Removal of adenoids                              T      0258     22.1165             1359.46           437.25           271.89
42835    Removal of adenoids                              T      0258     22.1165             1359.46           437.25           271.89
42836    Removal of adenoids                              T      0258     22.1165           $1,359.46         $437.25          $271.89
42842    Extensive surgery of throat                      T      0254     23.3299             1434.04           321.35           286.81
42844    Extensive surgery of throat                      T      0256     38.1991
                                                                   Milliman                   2348.02                             469.6
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
42845    Extensive surgery of throat                      C
42860    Excision of tonsil tags                          T      0258           22.1165       1359.46             437.25         271.89
42870    Excision of lingual tonsil                       T      0258           22.1165       1359.46             437.25         271.89
42890    Partial removal of pharynx                       T      0256           38.1991       2348.02                             469.6
42892    Revision of pharyngeal walls                     T      0256           38.1991       2348.02                             469.6
42894    Revision of pharyngeal walls                     C
42900    Repair throat wound                              T      0252            7.5511        464.15             109.16          92.83
42950    Reconstruction of throat                         T      0254           23.3299       1434.04             321.35         286.81
42953    Repair throat, esophagus                         C
42955    Surgical opening of throat                       T      0254           23.3299       1434.04             321.35         286.81
42960    Control throat bleeding                          T      0250            1.1791         72.48              25.39           14.5
42961    Control throat bleeding                          C
42962    Control throat bleeding                          T      0256           38.1991       2348.02                              469.6
42970    Control nose/throat bleeding                     T      0250            1.1791       $72.48              $25.39         $14.50
42971    Control nose/throat bleeding                     C
42972    Control nose/throat bleeding                     T      0253           16.4266     $1,009.71         $282.29          $201.94
42999    Throat surgery procedure                         T      0251            2.4520       $150.72                           $30.14
43020    Incision of esophagus                            T      0252            7.5511       $464.15         $109.16           $92.83
43030    Throat muscle surgery                            T      0253           16.4266        1009.71          282.29           201.94
43045    Incision of esophagus                            C
43100    Excision of esophagus lesion                     C
43101    Excision of esophagus lesion                     C
43107    Removal of esophagus                             C
43108    Removal of esophagus                             C
43112    Removal of esophagus                             C
43113    Removal of esophagus                             C
43116    Partial removal of esophagus                     C
43117    Partial removal of esophagus                     C
43118    Partial removal of esophagus                     C
43121    Partial removal of esophagus                     C
43122    Partial removal of esophagus                     C
43123    Partial removal of esophagus                     C
43124    Removal of esophagus                             C
43130    Removal of esophagus pouch               CH      T      0256           38.1991       2348.02                                 469.6
43135    Removal of esophagus pouch                       C
43200    Esophagus endoscopy                              T      0141       8.3175              511.26          143.38           102.25
43201    Esoph scope w/submucous inj                      T      0141       8.3175              511.26          143.38           102.25
43202    Esophagus endoscopy, biopsy                      T      0141       8.3175              511.26          143.38           102.25
43204    Esoph scope w/sclerosis inj                      T      0141       8.3175            $511.26         $143.38          $102.25
43205    Esophagus endoscopy/ligation                     T      0141       8.3175              511.26          143.38           102.25
43215    Esophagus endoscopy                              T      0141       8.3175            $511.26         $143.38          $102.25
43216    Esophagus endoscopy/lesion                       T      0141       8.3175              511.26          143.38           102.25
43217    Esophagus endoscopy                              T      0141       8.3175              511.26          143.38           102.25
43219    Esophagus endoscopy                              T      0384     22.9475              1410.54          295.41           282.11
43220    Esoph endoscopy, dilation                        T      0141       8.3175              511.26          143.38           102.25
43226    Esoph endoscopy, dilation                        T      0141       8.3175              511.26          143.38           102.25
43227    Esoph endoscopy, repair                          T      0141       8.3175              511.26          143.38           102.25
43228    Esoph endoscopy, ablation                        T      0422     25.7552              1583.12          448.81           316.62
43231    Esoph endoscopy w/us exam                        T      0141       8.3175              511.26          143.38           102.25
43232    Esoph endoscopy w/us fn bx                       T      0141       8.3175            $511.26         $143.38          $102.25
43234    Upper GI endoscopy, exam                         T      0141       8.3175              511.26          143.38           102.25
43235    Uppr gi endoscopy, diagnosis                     T      0141       8.3175              511.26          143.38           102.25
43236    Uppr gi scope w/submuc inj                       T        Milliman 8.3175
                                                                 0141                           511.26          143.38           102.25
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 49 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468     2007 CF
                                                                                                       National   Minimum
HCPCS/                                                                         Relative               Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate    Copayment Copayment
43237    Endoscopic us exam, esoph                        T      0141            8.3175     511.26         143.38     102.25
43238    Uppr gi endoscopy w/us fn bx                     T      0141            8.3175     511.26         143.38     102.25
43239    Upper GI endoscopy, biopsy                       T      0141            8.3175     511.26         143.38     102.25
43240    Esoph endoscope w/drain cyst                     T      0141            8.3175     511.26         143.38     102.25
43241    Upper GI endoscopy with tube                     T      0141            8.3175     511.26         143.38     102.25
43242    Uppr gi endoscopy w/us fn bx                     T      0141            8.3175     511.26         143.38     102.25
43243    Upper gi endoscopy & inject                      T      0141            8.3175     511.26         143.38     102.25
43244    Upper GI endoscopy/ligation                      T      0141            8.3175     511.26         143.38     102.25
43245    Uppr gi scope dilate strictr                     T      0141            8.3175     511.26         143.38     102.25
43246    Place gastrostomy tube                           T      0141            8.3175     511.26         143.38     102.25
43247    Operative upper GI endoscopy                     T      0141            8.3175     511.26         143.38     102.25
43248    Uppr gi endoscopy/guide wire                     T      0141            8.3175     511.26         143.38     102.25
43249    Esoph endoscopy, dilation                        T      0141            8.3175     511.26         143.38     102.25
43250    Upper GI endoscopy/tumor                         T      0141            8.3175     511.26         143.38     102.25
43251    Operative upper GI endoscopy                     T      0141            8.3175     511.26         143.38     102.25
43255    Operative upper GI endoscopy                     T      0141            8.3175     511.26         143.38     102.25
43256    Uppr gi endoscopy w/stent                        T      0384           22.9475   1410.54          295.41     282.11
43257    Uppr gi scope w/thrml txmnt                      T      0422           25.7552   1583.12          448.81     316.62
43258    Operative upper GI endoscopy                     T      0141            8.3175     511.26         143.38     102.25
43259    Endoscopic ultrasound exam                       T      0141            8.3175     511.26         143.38     102.25
43260    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43261    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43262    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43263    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43264    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43265    Endo cholangiopancreatograph                     T      0151           19.8381 $1,219.41        $245.46    $243.88
43267    Endo cholangiopancreatograph                     T      0151           19.8381 $1,219.41        $245.46    $243.88
43268    Endo cholangiopancreatograph                     T      0384           22.9475   1410.54          295.41     282.11
43269    Endo cholangiopancreatograph                     T      0384           22.9475   1410.54          295.41     282.11
43271    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43272    Endo cholangiopancreatograph                     T      0151           19.8381   1219.41          245.46     243.88
43280    Laparoscopy, fundoplasty                         T      0132           70.5066 $4,333.90      $1,239.22    $866.78
43289    Laparoscope proc, esoph                          T      0130           32.1241 $1,974.60        $659.53    $394.92
43300    Repair of esophagus                              C
43305    Repair esophagus and fistula                     C
43310    Repair of esophagus                              C
43312    Repair esophagus and fistula                     C
43313    Esophagoplasty congenital                        C
43314    Tracheo-esophagoplasty cong                      C
43320    Fuse esophagus & stomach                         C
43324    Revise esophagus & stomach                       C
43325    Revise esophagus & stomach                       C
43326    Revise esophagus & stomach                       C
43330    Repair of esophagus                              C
43331    Repair of esophagus                              C
43340    Fuse esophagus & intestine                       C
43341    Fuse esophagus & intestine                       C
43350    Surgical opening, esophagus                      C
43351    Surgical opening, esophagus                      C
43352    Surgical opening, esophagus                      C
43360    Gastrointestinal repair                          C
43361    Gastrointestinal repair                          C
43400    Ligate esophagus veins                           C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 50 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
43401    Esophagus surgery for veins                      C
43405    Ligate/staple esophagus                          C
43410    Repair esophagus wound                           C
43415    Repair esophagus wound                           C
43420    Repair esophagus opening                         C
43425    Repair esophagus opening                         C
43450    Dilate esophagus                                 T      0140            5.4566       $335.41             $91.40         $67.08
43453    Dilate esophagus                                 T      0140            5.4566       $335.41             $91.40         $67.08
43456    Dilate esophagus                                 T      0140            5.4566       $335.41             $91.40         $67.08
43458    Dilate esophagus                                 T      0140            5.4566       $335.41             $91.40         $67.08
43460    Pressure treatment esophagus                     C
43496    Free jejunum flap, microvasc                     C
43499    Esophagus surgery procedure                      T      0141            8.3175       $511.26         $143.38          $102.25
43500    Surgical opening of stomach                      C
43501    Surgical repair of stomach                       C
43502    Surgical repair of stomach                       C
43510    Surgical opening of stomach                      T      0141            8.3175       $511.26         $143.38          $102.25
43520    Incision of pyloric muscle                       C
43600    Biopsy of stomach                                T      0141            8.3175       $511.26         $143.38          $102.25
43605    Biopsy of stomach                                C
43610    Excision of stomach lesion                       C
43611    Excision of stomach lesion                       C
43620    Removal of stomach                               C
43621    Removal of stomach                               C
43622    Removal of stomach                               C
43631    Removal of stomach, partial                      C
43632    Removal of stomach, partial                      C
43633    Removal of stomach, partial                      C
43634    Removal of stomach, partial                      C
43635    Removal of stomach, partial                      C
43640    Vagotomy & pylorus repair                        C
43641    Vagotomy & pylorus repair                        C
43644    Lap gastric bypass/roux-en-y                     C
43645    Lap gastr bypass incl smll i                     C
43647    Lap impl electrode, antrum               NI      T      0130           32.1241         1974.6          659.53           394.92
43648    Lap revise/remv eltrd antrum             NI      T      0130           32.1241         1974.6          659.53           394.92
43651    Laparoscopy, vagus nerve                         T      0132           70.5066         4333.9         1239.22           866.78
43652    Laparoscopy, vagus nerve                         T      0132           70.5066         4333.9         1239.22           866.78
43653    Laparoscopy, gastrostomy                         T      0131           43.5488        2676.86         1001.89           535.37
43659    Laparoscope proc, stom                           T      0130           32.1241         1974.6          659.53           394.92
43750    Place gastrostomy tube                           T      0141            8.3175       $511.26         $143.38          $102.25
43752    Nasal/orogastric w/stent                         X      0272            1.2908          79.34           31.64            15.87
43760    Change gastrostomy tube                          T      0121            2.3587         144.98            43.8               29
43761    Reposition gastrostomy tube                      T      0122            7.4800         459.78                            91.96
43770    Lap, place gastr adjust band                     C
43771    Lap, revise adjust gast band                     C
43772    Lap, remove adjust gast band                     C
43773    Lap, change adjust gast band                     C
43774    Lap remov adj gast band/port                     C
43800    Reconstruction of pylorus                        C
43810    Fusion of stomach and bowel                      C
43820    Fusion of stomach and bowel                      C
43825    Fusion of stomach and bowel                      C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 51 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                    National            Minimum
HCPCS/                                                                         Relative            Unadjusted           Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment            Copayment
43830    Place gastrostomy tube                           T      0422           25.7552 $1,583.12     $448.81              $316.62
43831    Place gastrostomy tube                           T      0141            8.3175   $511.26     $143.38              $102.25
43832    Place gastrostomy tube                           C
43840    Repair of stomach lesion                         C
43842    V-band gastroplasty                              E
43843    Gastroplasty w/o v-band                          C
43845    Gastroplasty duodenal switch                     C
43846    Gastric bypass for obesity                       C
43847    Gastric bypass incl small i                      C
43848    Revision gastroplasty                            C
43850    Revise stomach-bowel fusion                      C
43855    Revise stomach-bowel fusion                      C
43860    Revise stomach-bowel fusion                      C
43865    Revise stomach-bowel fusion                      C
43870    Repair stomach opening                           T      0141            8.3175     511.26            143.38         102.25
43880    Repair stomach-bowel fistula                     C
43881    Impl/redo electrd, antrum                NI      C
43882    Revise/remove electrd antrum             NI      C
43886    Revise gastric port, open                        T      0025            5.2594    $323.28        $101.85           $64.66
43887    Remove gastric port, open                        T      0025            5.2594    $323.28        $101.85           $64.66
43888    Change gastric port, open                        T      0686           14.0346    $862.68                         $172.54
43999    Stomach surgery procedure                        T      0141            8.3175    $511.26        $143.38          $102.25
44005    Freeing of bowel adhesion                        C
44010    Incision of small bowel                          C
44015    Insert needle cath bowel                         C
44020    Explore small intestine                          C
44021    Decompress small bowel                           C
44025    Incision of large bowel                          C
44050    Reduce bowel obstruction                         C
44055    Correct malrotation of bowel                     C
44100    Biopsy of bowel                                  T      0141            8.3175    $511.26        $143.38          $102.25
44110    Excise intestine lesion(s)                       C
44111    Excision of bowel lesion(s)                      C
44120    Removal of small intestine                       C
44121    Removal of small intestine                       C
44125    Removal of small intestine                       C
44126    Enterectomy w/o taper, cong                      C
44127    Enterectomy w/taper, cong                        C
44128    Enterectomy cong, add-on                         C
44130    Bowel to bowel fusion                            C
44132    Enterectomy, cadaver donor                       C
44133    Enterectomy, live donor                          C
44135    Intestine transplnt, cadaver                     C
44136    Intestine transplant, live                       C
44137    Remove intestinal allograft                      C
44139    Mobilization of colon                            C
44140    Partial removal of colon                         C
44141    Partial removal of colon                         C
44143    Partial removal of colon                         C
44144    Partial removal of colon                         C
44145    Partial removal of colon                         C
44146    Partial removal of colon                         C
44147    Partial removal of colon                         C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 52 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National         Minimum
HCPCS/                                                                         Relative                Unadjusted        Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment         Copayment
44150    Removal of colon                                 C
44151    Removal of colon/ileostomy                       C
44152    Removal of colon/ileostomy               CH      D
44153    Removal of colon/ileostomy               CH      D
44155    Removal of colon/ileostomy                       C
44156    Removal of colon/ileostomy                       C
44157    Colectomy w/ileoanal anast               NI      C
44158    Colectomy w/neo-rectum pouch             NI      C
44160    Removal of colon                                 C
44180    Lap, enterolysis                                 T      0131           43.5488       2676.86        1001.89          535.37
44186    Lap, jejunostomy                                 T      0131           43.5488     $2,676.86      $1,001.89        $535.37
44187    Lap, ileo/jejuno-stomy                           C
44188    Lap, colostomy                                   C
44202    Lap, enterectomy                                 C
44203    Lap resect s/intestine, addl                     C
44204    Laparo partial colectomy                         C
44205    Lap colectomy part w/ileum                       C
44206    Lap part colectomy w/stoma                       T      0132           70.5066     $4,333.90      $1,239.22        $866.78
44207    Lcolectomy/coloproctostomy                       T      0132           70.5066     $4,333.90      $1,239.22        $866.78
44208    Lcolectomy/coloproctostomy                       T      0132           70.5066     $4,333.90      $1,239.22        $866.78
44210    Laparo total proctocolectomy                     C
44211    Lap colectomy w/proctectomy                      C
44212    Laparo total proctocolectomy                     C
44213    Lap, mobil splenic fl add-on                     T      0130           32.1241     $1,974.60        $659.53        $394.92
44227    Lap, close enterostomy                           C
44238    Laparoscope proc, intestine                      T      0130           32.1241     $1,974.60        $659.53        $394.92
44300    Open bowel to skin                               C
44310    Ileostomy/jejunostomy                            C
44312    Revision of ileostomy                            T      0027           21.4302     $1,317.27        $329.72        $263.45
44314    Revision of ileostomy                            C
44316    Devise bowel pouch                               C
44320    Colostomy                                        C
44322    Colostomy with biopsies                          C
44340    Revision of colostomy                            T      0027           21.4302     $1,317.27        $329.72        $263.45
44345    Revision of colostomy                            C
44346    Revision of colostomy                            C
44360    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44361    Small bowel endoscopy/biopsy                     T      0142       9.4946            $583.61        $152.78        $116.72
44363    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44364    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44365    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44366    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44369    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44370    Small bowel endoscopy/stent                      T      0384     22.9475           $1,410.54        $295.41        $282.11
44372    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44373    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44376    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44377    Small bowel endoscopy/biopsy                     T      0142       9.4946            $583.61        $152.78        $116.72
44378    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44379    Sbowel endoscope w/stent                         T      0384     22.9475           $1,410.54        $295.41        $282.11
44380    Small bowel endoscopy                            T      0142       9.4946            $583.61        $152.78        $116.72
44382    Small bowel endoscopy                            T      0142       9.4946            $583.61          152.78       $116.72
44383    Ileoscopy w/stent                                T      0384     22.9475
                                                                   Milliman                 $1,410.54        $295.41        $282.11
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 53 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468          2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
44385    Endoscopy of bowel pouch                         T      0143            8.7686       $538.99     $186.06    $107.80
44386    Endoscopy, bowel pouch/biop                      T      0143            8.7686       $538.99     $186.06    $107.80
44388    Colonoscopy                                      T      0143            8.7686       $538.99     $186.06    $107.80
44389    Colonoscopy with biopsy                          T      0143            8.7686       $538.99     $186.06    $107.80
44390    Colonoscopy for foreign body                     T      0143            8.7686       $538.99     $186.06    $107.80
44391    Colonoscopy for bleeding                         T      0143            8.7686       $538.99     $186.06    $107.80
44392    Colonoscopy & polypectomy                        T      0143            8.7686       $538.99     $186.06    $107.80
44393    Colonoscopy, lesion removal                      T      0143            8.7686       $538.99     $186.06    $107.80
44394    Colonoscopy w/snare                              T      0143            8.7686         538.99      186.06      107.8
44397    Colonoscopy w/stent                              T      0384           22.9475     $1,410.54     $295.41    $282.11
44500    Intro, gastrointestinal tube                     T      0121            2.3587         144.98        43.8         29
44602    Suture, small intestine                          C
44603    Suture, small intestine                          C
44604    Suture, large intestine                          C
44605    Repair of bowel lesion                           C
44615    Intestinal stricturoplasty                       C
44620    Repair bowel opening                             C
44625    Repair bowel opening                             C
44626    Repair bowel opening                             C
44640    Repair bowel-skin fistula                        C
44650    Repair bowel fistula                             C
44660    Repair bowel-bladder fistula                     C
44661    Repair bowel-bladder fistula                     C
44680    Surgical revision, intestine                     C
44700    Suspend bowel w/prosthesis                       C
44701    Intraop colon lavage add-on                      N
44715    Prepare donor intestine                          C
44720    Prep donor intestine/venous                      C
44721    Prep donor intestine/artery                      C
44799    Unlisted procedure intestine             CH      T      0153           22.0832     $1,357.41         $397.95        $271.48
44800    Excision of bowel pouch                          C
44820    Excision of mesentery lesion                     C
44850    Repair of mesentery                              C
44899    Bowel surgery procedure                          C
44900    Drain app abscess, open                          C
44901    Drain app abscess, percut                        T      0037           10.2655      $631.00          $228.76        $126.20
44950    Appendectomy                                     C
44955    Appendectomy add-on                              C
44960    Appendectomy                                     C
44970    Laparoscopy, appendectomy                        T      0131           43.5488     $2,676.86       $1,001.89        $535.37
44979    Laparoscope proc, app                            T      0130           32.1241     $1,974.60         $659.53        $394.92
45000    Drainage of pelvic abscess                       T      0148            5.0770       $312.07                         $62.41
45005    Drainage of rectal abscess                       T      0155           12.7389       $783.03                        $156.61
45020    Drainage of rectal abscess                       T      0155           12.7389         783.03                         156.61
45100    Biopsy of rectum                                 T      0149           22.2682        1368.78          293.06         273.76
45108    Removal of anorectal lesion              CH      T      0149           22.2682     $1,368.78         $293.06        $273.76
45110    Removal of rectum                                C
45111    Partial removal of rectum                        C
45112    Removal of rectum                                C
45113    Partial proctectomy                              C
45114    Partial removal of rectum                        C
45116    Partial removal of rectum                        C
45119    Remove rectum w/reservoir                        C        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment             Copayment
45120    Removal of rectum                                C
45121    Removal of rectum and colon                      C
45123    Partial proctectomy                              C
45126    Pelvic exenteration                              C
45130    Excision of rectal prolapse                      C
45135    Excision of rectal prolapse                      C
45136    Excise ileoanal reservior                        C
45150    Excision of rectal stricture                     T      0149           22.2682        1368.78          293.06            273.76
45160    Excision of rectal lesion                CH      T      0149           22.2682     $1,368.78         $293.06           $273.76
45170    Excision of rectal lesion                CH      T      0149           22.2682     $1,368.78         $293.06           $273.76
45190    Destruction, rectal tumor                CH      T      0149           22.2682     $1,368.78         $293.06           $273.76
45300    Proctosigmoidoscopy dx                           T      0146            4.8683         299.24            64.4             59.85
45303    Proctosigmoidoscopy dilate                       T      0147            8.5477         525.41                            105.08
45305    Proctosigmoidoscopy w/bx                         T      0147            8.5477       $525.41                           $105.08
45307    Proctosigmoidoscopy fb                           T      0428           20.6375     $1,268.55                           $253.71
45308    Proctosigmoidoscopy removal                      T      0147            8.5477         525.41                            105.08
45309    Proctosigmoidoscopy removal                      T      0147            8.5477         525.41                            105.08
45315    Proctosigmoidoscopy removal                      T      0147            8.5477         525.41                            105.08
45317    Proctosigmoidoscopy bleed                        T      0147            8.5477         525.41                            105.08
45320    Proctosigmoidoscopy ablate                       T      0428           20.6375        1268.55                            253.71
45321    Proctosigmoidoscopy volvul                       T      0428           20.6375     $1,268.55                           $253.71
45327    Proctosigmoidoscopy w/stent                      T      0384           22.9475        1410.54             295.41         282.11
45330    Diagnostic sigmoidoscopy                         T      0146            4.8683         299.24               64.4          59.85
45331    Sigmoidoscopy and biopsy                         T      0146            4.8683       $299.24             $64.40         $59.85
45332    Sigmoidoscopy w/fb removal                       T      0146            4.8683       $299.24             $64.40         $59.85
45333    Sigmoidoscopy & polypectomy                      T      0147            8.5477       $525.41                           $105.08
45334    Sigmoidoscopy for bleeding                       T      0147            8.5477       $525.41                           $105.08
45335    Sigmoidoscopy w/submuc inj                       T      0146            4.8683         299.24               64.4          59.85
45337    Sigmoidoscopy & decompress                       T      0146            4.8683       $299.24             $64.40         $59.85
45338    Sigmoidoscopy w/tumr remove                      T      0147            8.5477       $525.41                           $105.08
45339    Sigmoidoscopy w/ablate tumr                      T      0147            8.5477       $525.41                           $105.08
45340    Sig w/balloon dilation                           T      0147            8.5477       $525.41                           $105.08
45341    Sigmoidoscopy w/ultrasound                       T      0147            8.5477       $525.41                           $105.08
45342    Sigmoidoscopy w/us guide bx                      T      0147            8.5477       $525.41                           $105.08
45345    Sigmoidoscopy w/stent                            T      0384           22.9475     $1,410.54         $295.41           $282.11
45355    Surgical colonoscopy                             T      0143            8.7686       $538.99         $186.06           $107.80
45378    Diagnostic colonoscopy                           T      0143            8.7686       $538.99         $186.06           $107.80
45379    Colonoscopy w/fb removal                         T      0143            8.7686       $538.99         $186.06           $107.80
45380    Colonoscopy and biopsy                           T      0143            8.7686         538.99          186.06             107.8
45381    Colonoscopy, submucous inj                       T      0143            8.7686       $538.99         $186.06           $107.80
45382    Colonoscopy/control bleeding                     T      0143            8.7686         538.99          186.06             107.8
45383    Lesion removal colonoscopy                       T      0143            8.7686         538.99          186.06             107.8
45384    Lesion remove colonoscopy                        T      0143            8.7686         538.99          186.06             107.8
45385    Lesion removal colonoscopy                       T      0143            8.7686         538.99          186.06             107.8
45386    Colonoscopy dilate stricture                     T      0143            8.7686         538.99          186.06             107.8
45387    Colonoscopy w/stent                              T      0384           22.9475     $1,410.54         $295.41           $282.11
45391    Colonoscopy w/endoscope us                       T      0143            8.7686         538.99          186.06             107.8
45392    Colonoscopy w/endoscopic fnb                     T      0143            8.7686         538.99          186.06             107.8
45395    Lap, removal of rectum                           C
45397    Lap, remove rectum w/pouch                       C
45400    Laparoscopic proctopexy                          C
45402    Lap proctopexy w/sig resect                      C
45499    Laparoscope proc, rectum                         T      0130     32.1241
                                                                   Milliman                    1974.6             659.53          394.92
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                    National   Minimum
HCPCS/                                                                         Relative            Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment Copayment
45500    Repair of rectum                                 T      0149           22.2682   1368.78       293.06     273.76
45505    Repair of rectum                                 T      0150           29.6189   1820.61       437.12     364.12
45520    Treatment of rectal prolapse                     T      0098            1.0798     66.37                   13.27
45540    Correct rectal prolapse                          C
45541    Correct rectal prolapse                          T      0150           29.6189     1820.61             437.12         364.12
45550    Repair rectum/remove sigmoid                     C
45560    Repair of rectocele                              T      0150           29.6189     1820.61             437.12         364.12
45562    Exploration/repair of rectum                     C
45563    Exploration/repair of rectum                     C
45800    Repair rect/bladder fistula                      C
45805    Repair fistula w/colostomy                       C
45820    Repair rectourethral fistula                     C
45825    Repair fistula w/colostomy                       C
45900    Reduction of rectal prolapse                     T      0148       5.0770            312.07                            62.41
45905    Dilation of anal sphincter                       T      0149     22.2682            1368.78            293.06         273.76
45910    Dilation of rectal narrowing                     T      0149     22.2682            1368.78            293.06         273.76
45915    Remove rectal obstruction                        T      0148       5.0770            312.07                            62.41
45990    Surg dx exam, anorectal                          T      0148       5.0770          $312.07                           $62.41
45999    Rectum surgery procedure                         T      0148       5.0770            312.07                            62.41
46020    Placement of seton                       CH      T      0149     22.2682            1368.78            293.06         273.76
46030    Removal of rectal marker                         T      0148       5.0770            312.07                            62.41
46040    Incision of rectal abscess                       T      0149     22.2682            1368.78            293.06         273.76
46045    Incision of rectal abscess               CH      T      0149     22.2682            1368.78            293.06         273.76
46050    Incision of anal abscess                         T      0148       5.0770            312.07                            62.41
46060    Incision of rectal abscess               CH      T      0149     22.2682            1368.78            293.06         273.76
46070    Incision of anal septum                          T      0155     12.7389             783.03                           156.61
46080    Incision of anal sphincter                       T      0149     22.2682            1368.78            293.06         273.76
46083    Incise external hemorrhoid               CH      T      0164       2.1393             131.5                             26.3
46200    Removal of anal fissure                  CH      T      0149     22.2682            1368.78            293.06         273.76
46210    Removal of anal crypt                            T      0149     22.2682            1368.78            293.06         273.76
46211    Removal of anal crypts                   CH      T      0149     22.2682            1368.78            293.06         273.76
46220    Removal of anal tag                              T      0149     22.2682            1368.78            293.06         273.76
46221    Ligation of hemorrhoid(s)                        T      0148       5.0770            312.07                            62.41
46230    Removal of anal tags                             T      0149     22.2682         $1,368.78         $293.06          $273.76
46250    Hemorrhoidectomy                         CH      T      0149     22.2682            1368.78          293.06           273.76
46255    Hemorrhoidectomy                         CH      T      0149     22.2682            1368.78          293.06           273.76
46257    Remove hemorrhoids & fissure             CH      T      0149     22.2682            1368.78          293.06           273.76
46258    Remove hemorrhoids & fistula             CH      T      0149     22.2682            1368.78          293.06           273.76
46260    Hemorrhoidectomy                         CH      T      0149     22.2682            1368.78          293.06           273.76
46261    Remove hemorrhoids & fissure             CH      T      0149     22.2682            1368.78          293.06           273.76
46262    Remove hemorrhoids & fistula             CH      T      0149     22.2682            1368.78          293.06           273.76
46270    Removal of anal fistula                  CH      T      0149     22.2682         $1,368.78         $293.06          $273.76
46275    Removal of anal fistula                  CH      T      0149     22.2682            1368.78          293.06           273.76
46280    Removal of anal fistula                  CH      T      0149     22.2682            1368.78          293.06           273.76
46285    Removal of anal fistula                  CH      T      0149     22.2682            1368.78          293.06           273.76
46288    Repair anal fistula                      CH      T      0149     22.2682            1368.78          293.06           273.76
46320    Removal of hemorrhoid clot               CH      T      0155     12.7389             783.03                           156.61
46500    Injection into hemorrhoid(s)                     T      0155     12.7389             783.03                           156.61
46505    Chemodenervation anal musc                       T      0148       5.0770            312.07                            62.41
46600    Diagnostic anoscopy                              X      0340       0.6102             37.51                              7.5
46604    Anoscopy and dilation                            T      0147       8.5477            525.41                           105.08
46606    Anoscopy and biopsy                              T      0146       4.8683            299.24              64.4          59.85
46608    Anoscopy, remove for body                        T        Milliman 8.5477
                                                                 0147                       $525.41                          $105.08
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468          2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
46610    Anoscopy, remove lesion                          T      0428           20.6375     $1,268.55                $253.71
46611    Anoscopy                                         T      0147            8.5477       $525.41                $105.08
46612    Anoscopy, remove lesions                         T      0428           20.6375     $1,268.55                $253.71
46614    Anoscopy, control bleeding                       T      0146            4.8683       $299.24      $64.40     $59.85
46615    Anoscopy                                         T      0428           20.6375        1268.55                 253.71
46700    Repair of anal stricture                 CH      T      0149           22.2682        1368.78      293.06     273.76
46705    Repair of anal stricture                         C
46706    Repr of anal fistula w/glue                      T      0150           29.6189     $1,820.61         $437.12        $364.12
46710    Repr per/vag pouch sngl proc                     C
46712    Repr per/vag pouch dbl proc                      C
46715    Rep perf anoper fistu                            C
46716    Rep perf anoper/vestib fistu                     C
46730    Construction of absent anus                      C
46735    Construction of absent anus                      C
46740    Construction of absent anus                      C
46742    Repair of imperforated anus                      C
46744    Repair of cloacal anomaly                        C
46746    Repair of cloacal anomaly                        C
46748    Repair of cloacal anomaly                        C
46750    Repair of anal sphincter                 CH      T      0171           37.8991     $2,329.58         $716.76        $465.92
46751    Repair of anal sphincter                         C
46753    Reconstruction of anus                   CH      T      0149           22.2682        1368.78          293.06         273.76
46754    Removal of suture from anus                      T      0149           22.2682     $1,368.78         $293.06        $273.76
46760    Repair of anal sphincter                 CH      T      0171           37.8991        2329.58          716.76         465.92
46761    Repair of anal sphincter                 CH      T      0171           37.8991        2329.58          716.76         465.92
46762    Implant artificial sphincter             CH      T      0171           37.8991     $2,329.58         $716.76        $465.92
46900    Destruction, anal lesion(s)                      T      0016            2.6749       $164.42                         $32.88
46910    Destruction, anal lesion(s)                      T      0017           17.4423     $1,072.14         $227.84        $214.43
46916    Cryosurgery, anal lesion(s)                      T      0013            1.0918        $67.11                         $13.42
46917    Laser surgery, anal lesions                      T      0695           20.4276     $1,255.64         $266.59        $251.13
46922    Excision of anal lesion(s)                       T      0695           20.4276     $1,255.64         $266.59        $251.13
46924    Destruction, anal lesion(s)                      T      0695           20.4276     $1,255.64         $266.59        $251.13
46934    Destruction of hemorrhoids                       T      0155           12.7389       $783.03                        $156.61
46935    Destruction of hemorrhoids                       T      0155           12.7389       $783.03                        $156.61
46936    Destruction of hemorrhoids                       T      0149           22.2682     $1,368.78         $293.06        $273.76
46937    Cryotherapy of rectal lesion                     T      0149           22.2682     $1,368.78         $293.06        $273.76
46938    Cryotherapy of rectal lesion                     T      0150           29.6189     $1,820.61         $437.12        $364.12
46940    Treatment of anal fissure                        T      0149           22.2682     $1,368.78         $293.06        $273.76
46942    Treatment of anal fissure                        T      0148            5.0770       $312.07                         $62.41
46945    Ligation of hemorrhoids                          T      0155           12.7389       $783.03                        $156.61
46946    Ligation of hemorrhoids                          T      0155           12.7389       $783.03                        $156.61
46947    Hemorrhoidopexy by stapling                      T      0150           29.6189     $1,820.61         $437.12        $364.12
46999    Anus surgery procedure                           T      0148            5.0770       $312.07                         $62.41
47000    Needle biopsy of liver                           T      0685            6.1384       $377.32         $115.47         $75.46
47001    Needle biopsy, liver add-on                      N
47010    Open drainage, liver lesion                      C
47011    Percut drain, liver lesion                       T      0037           10.2655      $631.00          $228.76        $126.20
47015    Inject/aspirate liver cyst                       C
47100    Wedge biopsy of liver                            C
47120    Partial removal of liver                         C
47122    Extensive removal of liver                       C
47125    Partial removal of liver                         C
47130    Partial removal of liver                         C        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment             Copayment
47133    Removal of donor liver                           C
47135    Transplantation of liver                         C
47136    Transplantation of liver                         C
47140    Partial removal, donor liver                     C
47141    Partial removal, donor liver                     C
47142    Partial removal, donor liver                     C
47143    Prep donor liver, whole                          C
47144    Prep donor liver, 3-segment                      C
47145    Prep donor liver, lobe split                     C
47146    Prep donor liver/venous                          C
47147    Prep donor liver/arterial                        C
47300    Surgery for liver lesion                         C
47350    Repair liver wound                               C
47360    Repair liver wound                               C
47361    Repair liver wound                               C
47362    Repair liver wound                               C
47370    Laparo ablate liver tumor rf                     T      0132           70.5066     $4,333.90       $1,239.22           $866.78
47371    Laparo ablate liver cryosurg                     T      0131           43.5488       2676.86         1001.89             535.37
47379    Laparoscope procedure, liver                     T      0130           32.1241         1974.6          659.53            394.92
47380    Open ablate liver tumor rf                       C
47381    Open ablate liver tumor cryo                     C
47382    Percut ablate liver rf                           T      0423           37.3604       2296.47                             459.29
47399    Liver surgery procedure                  CH      T      0004            2.0687        127.16                              25.43
47400    Incision of liver duct                           C
47420    Incision of bile duct                            C
47425    Incision of bile duct                            C
47460    Incise bile duct sphincter                       C
47480    Incision of gallbladder                          C
47490    Incision of gallbladder                          T      0152           20.2682       1245.85                             249.17
47500    Injection for liver x-rays                       N
47505    Injection for liver x-rays                       N
47510    Insert catheter, bile duct                       T      0152           20.2682       1245.85                             249.17
47511    Insert bile duct drain                           T      0152           20.2682       1245.85                             249.17
47525    Change bile duct catheter                        T      0427           11.6575        716.56                             143.31
47530    Revise/reinsert bile tube                        T      0427           11.6575        716.56                             143.31
47550    Bile duct endoscopy add-on                       C
47552    Biliary endoscopy thru skin                      T      0152           20.2682       1245.85                             249.17
47553    Biliary endoscopy thru skin                      T      0152           20.2682       1245.85                             249.17
47554    Biliary endoscopy thru skin                      T      0152           20.2682       1245.85                             249.17
47555    Biliary endoscopy thru skin                      T      0152           20.2682       1245.85                             249.17
47556    Biliary endoscopy thru skin                      T      0152           20.2682       1245.85                             249.17
47560    Laparoscopy w/cholangio                          T      0130           32.1241        1974.6              659.53         394.92
47561    Laparo w/cholangio/biopsy                        T      0130           32.1241        1974.6              659.53         394.92
47562    Laparoscopic cholecystectomy                     T      0131           43.5488       2676.86             1001.89         535.37
47563    Laparo cholecystectomy/graph                     T      0131           43.5488       2676.86             1001.89         535.37
47564    Laparo cholecystectomy/explr                     T      0131           43.5488       2676.86             1001.89         535.37
47570    Laparo cholecystoenterostomy                     C
47579    Laparoscope proc, biliary                        T      0130           32.1241     $1,974.60         $659.53           $394.92
47600    Removal of gallbladder                           C
47605    Removal of gallbladder                           C
47610    Removal of gallbladder                           C
47612    Removal of gallbladder                           C
47620    Removal of gallbladder                           C        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                    National             Minimum
HCPCS/                                                                         Relative            Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment             Copayment
47630    Remove bile duct stone                           T      0152           20.2682 $1,245.85                           $249.17
47700    Exploration of bile ducts                        C
47701    Bile duct revision                               C
47711    Excision of bile duct tumor                      C
47712    Excision of bile duct tumor                      C
47715    Excision of bile duct cyst                       C
47716    Fusion of bile duct cyst                 CH      D
47719    Fusion of bile duct cyst                 NI      C
47720    Fuse gallbladder & bowel                         C
47721    Fuse upper gi structures                         C
47740    Fuse gallbladder & bowel                         C
47741    Fuse gallbladder & bowel                         C
47760    Fuse bile ducts and bowel                        C
47765    Fuse liver ducts & bowel                         C
47780    Fuse bile ducts and bowel                        C
47785    Fuse bile ducts and bowel                        C
47800    Reconstruction of bile ducts                     C
47801    Placement, bile duct support                     C
47802    Fuse liver duct & intestine                      C
47900    Suture bile duct injury                          C
47999    Bile tract surgery procedure                     T      0152           20.2682   $1,245.85                         $249.17
48000    Drainage of abdomen                              C
48001    Placement of drain, pancreas                     C
48005    Resect/debride pancreas                  CH      D
48020    Removal of pancreatic stone                      C
48100    Biopsy of pancreas, open                         C
48102    Needle biopsy, pancreas                          T      0685            6.1384      377.32            115.47              75.46
48105    Resect/debride pancreas                  NI      C
48120    Removal of pancreas lesion                       C
48140    Partial removal of pancreas                      C
48145    Partial removal of pancreas                      C
48146    Pancreatectomy                                   C
48148    Removal of pancreatic duct                       C
48150    Partial removal of pancreas                      C
48152    Pancreatectomy                                   C
48153    Pancreatectomy                                   C
48154    Pancreatectomy                                   C
48155    Removal of pancreas                              C
48160    Pancreas removal/transplant                      E
48180    Fuse pancreas and bowel                  CH      D
48400    Injection, intraop add-on                        C
48500    Surgery of pancreatic cyst                       C
48510    Drain pancreatic pseudocyst                      C
48511    Drain pancreatic pseudocyst                      T      0037           10.2655         631            228.76              126.2
48520    Fuse pancreas cyst and bowel                     C
48540    Fuse pancreas cyst and bowel                     C
48545    Pancreatorrhaphy                                 C
48547    Duodenal exclusion                               C
48548    Fuse pancreas and bowel                  NI      C
48550    Donor pancreatectomy                             E
48551    Prep donor pancreas                              C
48552    Prep donor pancreas/venous                       C
48554    Transpl allograft pancreas                       C        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
48556    Removal, allograft pancreas                      C
48999    Pancreas surgery procedure                       T      0004            2.0687        127.16                                 25.43
49000    Exploration of abdomen                           C
49002    Reopening of abdomen                             C
49010    Exploration behind abdomen                       C
49020    Drain abdominal abscess                          C
49021    Drain abdominal abscess                          T      0037           10.2655           631             228.76              126.2
49040    Drain, open, abdom abscess                       C
49041    Drain, percut, abdom abscess                     T      0037           10.2655           631             228.76              126.2
49060    Drain, open, retrop abscess                      C
49061    Drain, percut, retroper absc                     T      0037           10.2655           631             228.76              126.2
49062    Drain to peritoneal cavity                       C
49080    Puncture, peritoneal cavity                      T      0070            3.6244        222.78                                 44.56
49081    Removal of abdominal fluid                       T      0070            3.6244        222.78                                 44.56
49085    Remove abdomen foreign body              CH      D
49180    Biopsy, abdominal mass                           T      0685            6.1384        377.32             115.47          75.46
49200    Removal of abdominal lesion                      T      0130           32.1241        1974.6             659.53         394.92
49201    Remove abdom lesion, complex                     C
49215    Excise sacral spine tumor                        C
49220    Multiple surgery, abdomen                        C
49250    Excision of umbilicus                            T      0153           22.0832     $1,357.41         $397.95          $271.48
49255    Removal of omentum                               C
49320    Diag laparo separate proc                        T      0130           32.1241     $1,974.60         $659.53          $394.92
49321    Laparoscopy, biopsy                              T      0130           32.1241     $1,974.60         $659.53          $394.92
49322    Laparoscopy, aspiration                          T      0130           32.1241     $1,974.60         $659.53          $394.92
49323    Laparo drain lymphocele                          T      0130           32.1241     $1,974.60         $659.53          $394.92
49324    Lap insertion perm ip cath               NI      T      0130           32.1241     $1,974.60         $659.53          $394.92
49325    Lap revision perm ip cath                NI      T      0130           32.1241     $1,974.60         $659.53          $394.92
49326    Lap w/omentopexy add-on                  NI      T      0130           32.1241     $1,974.60         $659.53          $394.92
49329    Laparo proc, abdm/per/oment                      T      0130           32.1241     $1,974.60         $659.53          $394.92
49400    Air injection into abdomen                       N
49402    Remove foreign body, adbomen             NI      T      0153           22.0832     $1,357.41         $397.95          $271.48
49419    Insrt abdom cath for chemotx                     T      0115           29.2133     $1,795.68         $374.81          $359.14
49420    Insert abdom drain, temp                         T      0652           29.5416     $1,815.86                          $363.17
49421    Insert abdom drain, perm                         T      0652           29.5416     $1,815.86                          $363.17
49422    Remove perm cannula/catheter                     T      0105           25.6142     $1,574.45              370.4       $314.89
49423    Exchange drainage catheter                       T      0427           11.6575       $716.56                          $143.31
49424    Assess cyst, contrast inject                     N
49425    Insert abdomen-venous drain                      C
49426    Revise abdomen-venous shunt                      T      0153           22.0832     $1,357.41         $397.95          $271.48
49427    Injection, abdominal shunt                       N
49428    Ligation of shunt                                C
49429    Removal of shunt                                 T      0105     25.6142           $1,574.45              370.4       $314.89
49435    Insert subq exten to ip cath             NI      T      0427     11.6575             $716.56                          $143.31
49436    Embedded ip cath exit-site               NI      T      0427     11.6575             $716.56                          $143.31
49491    Rpr hern preemie reduc                           T      0154     29.2182           $1,795.98             464.85       $359.20
49492    Rpr ing hern premie, blocked                     T      0154     29.2182              1795.98            464.85          359.2
49495    Rpr ing hernia baby, reduc                       T      0154     29.2182              1795.98            464.85          359.2
49496    Rpr ing hernia baby, blocked                     T      0154     29.2182              1795.98            464.85          359.2
49500    Rpr ing hernia, init, reduce                     T      0154     29.2182              1795.98            464.85          359.2
49501    Rpr ing hernia, init blocked                     T      0154     29.2182              1795.98            464.85          359.2
49505    Prp i/hern init reduc >5 yr                      T      0154     29.2182              1795.98            464.85          359.2
49507    Prp i/hern init block >5 yr                      T      0154     29.2182
                                                                   Milliman                    1795.98            464.85          359.2
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 60 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                         National   Minimum
HCPCS/                                                                         Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate      Copayment Copayment
49520    Rerepair ing hernia, reduce                      T      0154           29.2182   1795.98            464.85      359.2
49521    Rerepair ing hernia, blocked                     T      0154           29.2182   1795.98            464.85      359.2
49525    Repair ing hernia, sliding                       T      0154           29.2182   1795.98            464.85      359.2
49540    Repair lumbar hernia                             T      0154           29.2182   1795.98            464.85      359.2
49550    Rpr rem hernia, init, reduce                     T      0154           29.2182   1795.98            464.85      359.2
49553    Rpr fem hernia, init blocked                     T      0154           29.2182   1795.98            464.85      359.2
49555    Rerepair fem hernia, reduce                      T      0154           29.2182   1795.98            464.85      359.2
49557    Rerepair fem hernia, blocked                     T      0154           29.2182   1795.98            464.85      359.2
49560    Rpr ventral hern init, reduc                     T      0154           29.2182   1795.98            464.85      359.2
49561    Rpr ventral hern init, block                     T      0154           29.2182   1795.98            464.85      359.2
49565    Rerepair ventrl hern, reduce                     T      0154           29.2182 $1,795.98          $464.85    $359.20
49566    Rerepair ventrl hern, block                      T      0154           29.2182   1795.98            464.85      359.2
49568    Hernia repair w/mesh                             T      0154           29.2182   1795.98            464.85      359.2
49570    Rpr epigastric hern, reduce                      T      0154           29.2182   1795.98            464.85      359.2
49572    Rpr epigastric hern, blocked                     T      0154           29.2182 $1,795.98          $464.85    $359.20
49580    Rpr umbil hern, reduc < 5 yr                     T      0154           29.2182 $1,795.98          $464.85    $359.20
49582    Rpr umbil hern, block < 5 yr                     T      0154           29.2182 $1,795.98          $464.85    $359.20
49585    Rpr umbil hern, reduc > 5 yr                     T      0154           29.2182 $1,795.98          $464.85    $359.20
49587    Rpr umbil hern, block > 5 yr                     T      0154           29.2182 $1,795.98          $464.85    $359.20
49590    Repair spigelian hernia                          T      0154           29.2182 $1,795.98          $464.85    $359.20
49600    Repair umbilical lesion                          T      0154           29.2182 $1,795.98          $464.85    $359.20
49605    Repair umbilical lesion                          C
49606    Repair umbilical lesion                          C
49610    Repair umbilical lesion                          C
49611    Repair umbilical lesion                          C
49650    Laparo hernia repair initial                     T      0131           43.5488   $2,676.86       $1,001.89          $535.37
49651    Laparo hernia repair recur                       T      0131           43.5488   $2,676.86       $1,001.89          $535.37
49659    Laparo proc, hernia repair                       T      0130           32.1241   $1,974.60         $659.53          $394.92
49900    Repair of abdominal wall                         C
49904    Omental flap, extra-abdom                        C
49905    Omental flap, intra-abdom                        C
49906    Free omental flap, microvasc                     C
49999    Abdomen surgery procedure                        T      0153           22.0832     1357.41             397.95         271.48
50010    Exploration of kidney                            C
50020    Renal abscess, open drain                        T      0162           23.8700     1467.24                            293.45
50021    Renal abscess, percut drain                      T      0037           10.2655         631             228.76          126.2
50040    Drainage of kidney                               C
50045    Exploration of kidney                            C
50060    Removal of kidney stone                          C
50065    Incision of kidney                               C
50070    Incision of kidney                               C
50075    Removal of kidney stone                          C
50080    Removal of kidney stone                          T      0429           43.1004       2649.3                           529.86
50081    Removal of kidney stone                          T      0429           43.1004   $2,649.30                          $529.86
50100    Revise kidney blood vessels                      C
50120    Exploration of kidney                            C
50125    Explore and drain kidney                         C
50130    Removal of kidney stone                          C
50135    Exploration of kidney                            C
50200    Biopsy of kidney                                 T      0685            6.1384    $377.32          $115.47            $75.46
50205    Biopsy of kidney                                 C
50220    Remove kidney, open                              C
50225    Removal kidney open, complex                     C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 61 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment            Copayment
50230    Removal kidney open, radical                     C
50234    Removal of kidney & ureter                       C
50236    Removal of kidney & ureter                       C
50240    Partial removal of kidney                        C
50250    Cryoablate renal mass open                       C
50280    Removal of kidney lesion                         C
50290    Removal of kidney lesion                         C
50300    Remove cadaver donor kidney                      C
50320    Remove kidney, living donor                      C
50323    Prep cadaver renal allograft                     C
50325    Prep donor renal graft                           C
50327    Prep renal graft/venous                          C
50328    Prep renal graft/arterial                        C
50329    Prep renal graft/ureteral                        C
50340    Removal of kidney                                C
50360    Transplantation of kidney                        C
50365    Transplantation of kidney                        C
50370    Remove transplanted kidney                       C
50380    Reimplantation of kidney                         C
50382    Change ureter stent, percut                      T      0161           19.2251     $1,181.73        $249.36           $236.35
50384    Remove ureter stent, percut                      T      0161           19.2251     $1,181.73          249.36          $236.35
50387    Change ext/int ureter stent                      T      0122            7.4800       $459.78                           $91.96
50389    Remove renal tube w/fluoro                       T      0156            3.4079       $209.48                           $41.90
50390    Drainage of kidney lesion                        T      0685            6.1384       $377.32             115.47        $75.46
50391    Instll rx agnt into rnal tub             CH      T      0126            1.0887        $66.92              16.45        $13.38
50392    Insert kidney drain                              T      0161           19.2251     $1,181.73             249.36       $236.35
50393    Insert ureteral tube                             T      0161           19.2251     $1,181.73             249.36       $236.35
50394    Injection for kidney x-ray                       N
50395    Create passage to kidney                         T      0161           19.2251     $1,181.73             249.36       $236.35
50396    Measure kidney pressure                          T      0164            2.1393       $131.50                           $26.30
50398    Change kidney tube                               T      0122            7.4800       $459.78                           $91.96
50400    Revision of kidney/ureter                        C
50405    Revision of kidney/ureter                        C
50500    Repair of kidney wound                           C
50520    Close kidney-skin fistula                        C
50525    Repair renal-abdomen fistula                     C
50526    Repair renal-abdomen fistula                     C
50540    Revision of horseshoe kidney                     C
50541    Laparo ablate renal cyst                         T      0130           32.1241     $1,974.60             659.53       $394.92
50542    Laparo ablate renal mass                         T      0132           70.5066     $4,333.90            1239.22       $866.78
50543    Laparo partial nephrectomy                       T      0131           43.5488     $2,676.86            1001.89       $535.37
50544    Laparoscopy, pyeloplasty                         T      0130           32.1241     $1,974.60             659.53       $394.92
50545    Laparo radical nephrectomy                       C
50546    Laparoscopic nephrectomy                         C
50547    Laparo removal donor kidney                      C
50548    Laparo remove w/ureter                           C
50549    Laparoscope proc, renal                          T      0130     32.1241           $1,974.60             659.53       $394.92
50551    Kidney endoscopy                                 T      0160       6.4951            $399.24             101.58        $79.85
50553    Kidney endoscopy                                 T      0161     19.2251           $1,181.73             249.36       $236.35
50555    Kidney endoscopy & biopsy                        T      0160       6.4951            $399.24             101.58        $79.85
50557    Kidney endoscopy & treatment                     T      0162     23.8700           $1,467.24                          $293.45
50561    Kidney endoscopy & treatment                     T      0161     19.2251           $1,181.73             249.36       $236.35
50562    Renal scope w/tumor resect                       T        Milliman 6.4951
                                                                 0160                         $399.24             101.58        $79.85
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 62 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
50570    Kidney endoscopy                                 T      0160            6.4951       $399.24       101.58    $79.85
50572    Kidney endoscopy                                 T      0160            6.4951       $399.24     $101.58     $79.85
50574    Kidney endoscopy & biopsy                        T      0160            6.4951       $399.24     $101.58     $79.85
50575    Kidney endoscopy                                 T      0163           34.9261     $2,146.84                $429.37
50576    Kidney endoscopy & treatment                     T      0161           19.2251     $1,181.73     $249.36    $236.35
50580    Kidney endoscopy & treatment                     C
50590    Fragmenting of kidney stone                      T      0169           43.5398     $2,676.30       $1,009.47          $535.26
50592    Perc rf ablate renal tumor                       T      0423           37.3604     $2,296.47                          $459.29
50600    Exploration of ureter                            C
50605    Insert ureteral support                          C
50610    Removal of ureter stone                          C
50620    Removal of ureter stone                          C
50630    Removal of ureter stone                          C
50650    Removal of ureter                                C
50660    Removal of ureter                                C
50684    Injection for ureter x-ray                       N
50686    Measure ureter pressure                  CH      T      0126            1.0887       $66.92              $16.45         $13.38
50688    Change of ureter tube/stent                      T      0122            7.4800      $459.78                             $91.96
50690    Injection for ureter x-ray                       N
50700    Revision of ureter                               C
50715    Release of ureter                                C
50722    Release of ureter                                C
50725    Release/revise ureter                            C
50727    Revise ureter                                    C
50728    Revise ureter                                    C
50740    Fusion of ureter & kidney                        C
50750    Fusion of ureter & kidney                        C
50760    Fusion of ureters                                C
50770    Splicing of ureters                              C
50780    Reimplant ureter in bladder                      C
50782    Reimplant ureter in bladder                      C
50783    Reimplant ureter in bladder                      C
50785    Reimplant ureter in bladder                      C
50800    Implant ureter in bowel                          C
50810    Fusion of ureter & bowel                         C
50815    Urine shunt to intestine                         C
50820    Construct bowel bladder                          C
50825    Construct bowel bladder                          C
50830    Revise urine flow                                C
50840    Replace ureter by bowel                          C
50845    Appendico-vesicostomy                            C
50860    Transplant ureter to skin                        C
50900    Repair of ureter                                 C
50920    Closure ureter/skin fistula                      C
50930    Closure ureter/bowel fistula                     C
50940    Release of ureter                                C
50945    Laparoscopy ureterolithotomy                     T      0131     43.5488           $2,676.86       $1,001.89          $535.37
50947    Laparo new ureter/bladder                        T      0131     43.5488           $2,676.86          1001.89         $535.37
50948    Laparo new ureter/bladder                        T      0131     43.5488           $2,676.86       $1,001.89          $535.37
50949    Laparoscope proc, ureter                         T      0130     32.1241           $1,974.60         $659.53          $394.92
50951    Endoscopy of ureter                              T      0160       6.4951            $399.24         $101.58           $79.85
50953    Endoscopy of ureter                              T      0160       6.4951            $399.24         $101.58           $79.85
50955    Ureter endoscopy & biopsy                        T      0161     19.2251
                                                                   Milliman                    1181.73          249.36           236.35
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 63 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
50957    Ureter endoscopy & treatment                     T      0161           19.2251     $1,181.73     $249.36    $236.35
50961    Ureter endoscopy & treatment                     T      0161           19.2251     $1,181.73       249.36   $236.35
50970    Ureter endoscopy                                 T      0160            6.4951       $399.24       101.58    $79.85
50972    Ureter endoscopy & catheter                      T      0160            6.4951       $399.24       101.58    $79.85
50974    Ureter endoscopy & biopsy                        T      0161           19.2251     $1,181.73     $249.36    $236.35
50976    Ureter endoscopy & treatment                     T      0161           19.2251     $1,181.73     $249.36    $236.35
50980    Ureter endoscopy & treatment                     T      0161           19.2251     $1,181.73     $249.36    $236.35
51000    Drainage of bladder                              T      0164            2.1393       $131.50                 $26.30
51005    Drainage of bladder                      CH      T      0126            1.0887        $66.92      $16.45     $13.38
51010    Drainage of bladder                              T      0165           18.1679     $1,116.74                $223.35
51020    Incise & treat bladder                           T      0162           23.8700     $1,467.24                $293.45
51030    Incise & treat bladder                           T      0162           23.8700     $1,467.24                $293.45
51040    Incise & drain bladder                           T      0162           23.8700     $1,467.24                $293.45
51045    Incise bladder/drain ureter                      T      0160            6.4951       $399.24     $101.58     $79.85
51050    Removal of bladder stone                         T      0162           23.8700     $1,467.24                $293.45
51060    Removal of ureter stone                          C
51065    Remove ureter calculus                           T      0162           23.8700     $1,467.24                           $293.45
51080    Drainage of bladder abscess                      T      0008           17.5086     $1,076.22                           $215.24
51500    Removal of bladder cyst                          T      0154           29.2182     $1,795.98         $464.85           $359.20
51520    Removal of bladder lesion                        T      0162           23.8700     $1,467.24                           $293.45
51525    Removal of bladder lesion                        C
51530    Removal of bladder lesion                        C
51535    Repair of ureter lesion                          C
51550    Partial removal of bladder                       C
51555    Partial removal of bladder                       C
51565    Revise bladder & ureter(s)                       C
51570    Removal of bladder                               C
51575    Removal of bladder & nodes                       C
51580    Remove bladder/revise tract                      C
51585    Removal of bladder & nodes                       C
51590    Remove bladder/revise tract                      C
51595    Remove bladder/revise tract                      C
51596    Remove bladder/create pouch                      C
51597    Removal of pelvic structures                     C
51600    Injection for bladder x-ray                      N
51605    Preparation for bladder xray                     N
51610    Injection for bladder x-ray                      N
51700    Irrigation of bladder                            T      0164       2.1393            $131.50                            $26.30
51701    Insert bladder catheter                          X      0340       0.6102             $37.51                             $7.50
51702    Insert temp bladder cath                         X      0340       0.6102             $37.51                             $7.50
51703    Insert bladder cath, complex             CH      T      0126       1.0887             $66.92             $16.45         $13.38
51705    Change of bladder tube                           T      0121       2.3587            $144.98             $43.80         $29.00
51710    Change of bladder tube                           T      0122       7.4800            $459.78                            $91.96
51715    Endoscopic injection/implant                     T      0168     29.0253           $1,784.13         $388.16           $356.83
51720    Treatment of bladder lesion              CH      T      0164       2.1393            $131.50                            $26.30
51725    Simple cystometrogram                    CH      T      0164       2.1393            $131.50                            $26.30
51726    Complex cystometrogram                           T      0156       3.4079            $209.48                            $41.90
51736    Urine flow measurement                   CH      T      0126       1.0887             $66.92             $16.45         $13.38
51741    Electro-uroflowmetry, first              CH      T      0126       1.0887             $66.92             $16.45         $13.38
51772    Urethra pressure profile                 CH      T      0164       2.1393               131.5                              26.3
51784    Anal/urinary muscle study                CH      T      0126       1.0887               66.92              16.45          13.38
51785    Anal/urinary muscle study                CH      T      0126       1.0887             $66.92             $16.45         $13.38
51792    Urinary reflex study                     CH      T      0126
                                                                   Milliman 1.0887             $66.92             $16.45         $13.38
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                          Page 64 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468          2007 CF
                                                                                                    National            Minimum
HCPCS/                                                                         Relative            Unadjusted           Unadjusted
CPT                Short Descriptor               CI      SI     APC           Weight Payment Rate Copayment            Copayment
51795    Urine voiding pressure study                     T      0164            2.1393   $131.50                           $26.30
51797    Intraabdominal pressure test                     T      0164            2.1393   $131.50                           $26.30
51798    Us urine capacity measure                        X      0340            0.6102    $37.51                            $7.50
51800    Revision of bladder/urethra                      C
51820    Revision of urinary tract                        C
51840    Attach bladder/urethra                           C
51841    Attach bladder/urethra                           C
51845    Repair bladder neck                              C
51860    Repair of bladder wound                          C
51865    Repair of bladder wound                          C
51880    Repair of bladder opening                        T      0162           23.8700   $1,467.24                        $293.45
51900    Repair bladder/vagina lesion                     C
51920    Close bladder-uterus fistula                     C
51925    Hysterectomy/bladder repair                      C
51940    Correction of bladder defect                     C
51960    Revision of bladder & bowel                      C
51980    Construct bladder opening                        C
51990    Laparo urethral suspension                       T      0131     43.5488            2676.86         1001.89         535.37
51992    Laparo sling operation                   CH      T      0131     43.5488         $2,676.86       $1,001.89        $535.37
51999    Laparoscope proc, bladder                        T      0130     32.1241         $1,974.60         $659.53        $394.92
52000    Cystoscopy                                       T      0160       6.4951          $399.24         $101.58         $79.85
52001    Cystoscopy, removal of clots                     T      0160       6.4951          $399.24         $101.58         $79.85
52005    Cystoscopy & ureter catheter                     T      0161     19.2251         $1,181.73           249.36       $236.35
52007    Cystoscopy and biopsy                            T      0161     19.2251         $1,181.73           249.36       $236.35
52010    Cystoscopy & duct catheter                       T      0160       6.4951          $399.24           101.58        $79.85
52204    Cystoscopy w/biopsy(s)                           T      0161     19.2251         $1,181.73           249.36       $236.35
52214    Cystoscopy and treatment                         T      0162     23.8700         $1,467.24                        $293.45
52224    Cystoscopy and treatment                         T      0162     23.8700            1467.24                         293.45
52234    Cystoscopy and treatment                         T      0162     23.8700         $1,467.24                        $293.45
52235    Cystoscopy and treatment                         T      0162     23.8700            1467.24                         293.45
52240    Cystoscopy and treatment                         T      0162     23.8700         $1,467.24                        $293.45
52250    Cystoscopy and radiotracer                       T      0162     23.8700         $1,467.24                        $293.45
52260    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73         $249.36        $236.35
52265    Cystoscopy and treatment                         T      0160       6.4951            399.24          101.58          79.85
52270    Cystoscopy & revise urethra                      T      0161     19.2251         $1,181.73           249.36       $236.35
52275    Cystoscopy & revise urethra                      T      0161     19.2251         $1,181.73           249.36       $236.35
52276    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52277    Cystoscopy and treatment                         T      0162     23.8700         $1,467.24                        $293.45
52281    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73         $249.36        $236.35
52282    Cystoscopy, implant stent                        T      0163     34.9261         $2,146.84                        $429.37
52283    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52285    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73         $249.36        $236.35
52290    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52300    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52301    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52305    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52310    Cystoscopy and treatment                         T      0160       6.4951          $399.24           101.58        $79.85
52315    Cystoscopy and treatment                         T      0161     19.2251         $1,181.73           249.36       $236.35
52317    Remove bladder stone                             T      0162     23.8700         $1,467.24                        $293.45
52318    Remove bladder stone                             T      0162     23.8700         $1,467.24                        $293.45
52320    Cystoscopy and treatment                         T      0162     23.8700         $1,467.24                        $293.45
52325    Cystoscopy, stone removal                        T      0162     23.8700         $1,467.24                        $293.45
52327    Cystoscopy, inject material                      T      0162     23.8700
                                                                   Milliman               $1,467.24                        $293.45
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 65 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468      2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
52330    Cystoscopy and treatment                         T      0162           23.8700     $1,467.24                $293.45
52332    Cystoscopy and treatment                         T      0162           23.8700     $1,467.24                $293.45
52334    Create passage to kidney                         T      0162           23.8700     $1,467.24                $293.45
52341    Cysto w/ureter stricture tx                      T      0162           23.8700     $1,467.24                $293.45
52342    Cysto w/up stricture tx                          T      0162           23.8700     $1,467.24                $293.45
52343    Cysto w/renal stricture tx                       T      0162           23.8700     $1,467.24                $293.45
52344    Cysto/uretero, stricture tx                      T      0162           23.8700     $1,467.24                $293.45
52345    Cysto/uretero w/up stricture                     T      0162           23.8700     $1,467.24                $293.45
52346    Cystouretero w/renal strict                      T      0162           23.8700       1467.24                  293.45
52351    Cystouretero & or pyeloscope                     T      0161           19.2251     $1,181.73       249.36   $236.35
52352    Cystouretero w/stone remove                      T      0162           23.8700     $1,467.24                $293.45
52353    Cystouretero w/lithotripsy                       T      0163           34.9261     $2,146.84                $429.37
52354    Cystouretero w/biopsy                            T      0162           23.8700     $1,467.24                $293.45
52355    Cystouretero w/excise tumor                      T      0162           23.8700     $1,467.24                $293.45
52400    Cystouretero w/congen repr                       T      0162           23.8700     $1,467.24                $293.45
52402    Cystourethro cut ejacul duct                     T      0162           23.8700     $1,467.24                $293.45
52450    Incision of prostate                             T      0162           23.8700     $1,467.24                $293.45
52500    Revision of bladder neck                         T      0162           23.8700     $1,467.24                $293.45
52510    Dilation prostatic urethra                       T      0161           19.2251       1181.73       249.36     236.35
52601    Prostatectomy (TURP)                             T      0163           34.9261       2146.84                  429.37
52606    Control postop bleeding                          T      0162           23.8700       1467.24                  293.45
52612    Prostatectomy, first stage                       T      0163           34.9261     $2,146.84                $429.37
52614    Prostatectomy, second stage                      T      0163           34.9261     $2,146.84                $429.37
52620    Remove residual prostate                         T      0163           34.9261     $2,146.84                $429.37
52630    Remove prostate regrowth                         T      0163           34.9261     $2,146.84                $429.37
52640    Relieve bladder contracture                      T      0162           23.8700     $1,467.24                $293.45
52647    Laser surgery of prostate                        T      0429           43.1004         2649.3                 529.86
52648    Laser surgery of prostate                        T      0429           43.1004         2649.3                 529.86
52700    Drainage of prostate abscess                     T      0162           23.8700       1467.24                  293.45
53000    Incision of urethra                              T      0166           18.3960       1130.77                  226.15
53010    Incision of urethra                              T      0166           18.3960       1130.77                  226.15
53020    Incision of urethra                              T      0166           18.3960       1130.77                  226.15
53025    Incision of urethra                              T      0166           18.3960       1130.77                  226.15
53040    Drainage of urethra abscess                      T      0166           18.3960       1130.77                  226.15
53060    Drainage of urethra abscess                      T      0166           18.3960       1130.77                  226.15
53080    Drainage of urinary leakage                      T      0166           18.3960     $1,130.77                $226.15
53085    Drainage of urinary leakage                      T      0166           18.3960     $1,130.77                $226.15
53200    Biopsy of urethra                                T      0166           18.3960       1130.77                  226.15
53210    Removal of urethra                               T      0168           29.0253       1784.13       388.16     356.83
53215    Removal of urethra                               T      0166           18.3960       1130.77                  226.15
53220    Treatment of urethra lesion                      T      0168           29.0253     $1,784.13     $388.16    $356.83
53230    Removal of urethra lesion                        T      0168           29.0253     $1,784.13       388.16   $356.83
53235    Removal of urethra lesion                        T      0166           18.3960     $1,130.77                $226.15
53240    Surgery for urethra pouch                        T      0168           29.0253       1784.13       388.16     356.83
53250    Removal of urethra gland                         T      0166           18.3960       1130.77                  226.15
53260    Treatment of urethra lesion                      T      0166           18.3960     $1,130.77                $226.15
53265    Treatment of urethra lesion                      T      0166           18.3960     $1,130.77                $226.15
53270    Removal of urethra gland                         T      0166           18.3960     $1,130.77                $226.15
53275    Repair of urethra defect                         T      0166           18.3960     $1,130.77                $226.15
53400    Revise urethra, stage 1                          T      0168           29.0253     $1,784.13     $388.16    $356.83
53405    Revise urethra, stage 2                          T      0168           29.0253     $1,784.13     $388.16    $356.83
53410    Reconstruction of urethra                        T      0168           29.0253     $1,784.13     $388.16    $356.83
53415    Reconstruction of urethra                        C        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                               Page 66 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
53420    Reconstruct urethra, stage 1                     T      0168           29.0253     $1,784.13     $388.16    $356.83
53425    Reconstruct urethra, stage 2                     T      0168           29.0253     $1,784.13     $388.16    $356.83
53430    Reconstruction of urethra                        T      0168           29.0253       1784.13       388.16     356.83
53431    Reconstruct urethra/bladder                      T      0168           29.0253       1784.13       388.16     356.83
53440    Male sling procedure                             S      0385           79.2092       4868.83                  973.77
53442    Remove/revise male sling                         T      0168           29.0253       1784.13       388.16     356.83
53444    Insert tandem cuff                               S      0385           79.2092       4868.83                  973.77
53445    Insert uro/ves nck sphincter                     S      0386          137.3897       8445.07                 1689.01
53446    Remove uro sphincter                             T      0168           29.0253       1784.13       388.16     356.83
53447    Remove/replace ur sphincter                      S      0386          137.3897     $8,445.07              $1,689.01
53448    Remov/replc ur sphinctr comp                     C
53449    Repair uro sphincter                             T      0168           29.0253     $1,784.13         $388.16          $356.83
53450    Revision of urethra                              T      0168           29.0253     $1,784.13         $388.16          $356.83
53460    Revision of urethra                              T      0166           18.3960     $1,130.77                          $226.15
53500    Urethrlys, transvag w/ scope                     T      0168           29.0253     $1,784.13         $388.16          $356.83
53502    Repair of urethra injury                         T      0166           18.3960     $1,130.77                          $226.15
53505    Repair of urethra injury                         T      0168           29.0253     $1,784.13         $388.16          $356.83
53510    Repair of urethra injury                         T      0166           18.3960     $1,130.77                          $226.15
53515    Repair of urethra injury                         T      0168           29.0253     $1,784.13         $388.16          $356.83
53520    Repair of urethra defect                         T      0168           29.0253     $1,784.13         $388.16          $356.83
53600    Dilate urethra stricture                         T      0156            3.4079       $209.48                           $41.90
53601    Dilate urethra stricture                 CH      T      0126            1.0887        $66.92          $16.45           $13.38
53605    Dilate urethra stricture                         T      0161           19.2251     $1,181.73         $249.36          $236.35
53620    Dilate urethra stricture                         T      0165           18.1679     $1,116.74                          $223.35
53621    Dilate urethra stricture                         T      0164            2.1393       $131.50                           $26.30
53660    Dilation of urethra                      CH      T      0126            1.0887        $66.92             $16.45        $13.38
53661    Dilation of urethra                      CH      T      0126            1.0887        $66.92             $16.45        $13.38
53665    Dilation of urethra                              T      0166           18.3960     $1,130.77                          $226.15
53850    Prostatic microwave thermotx                     T      0675           41.1375     $2,528.64                          $505.73
53852    Prostatic rf thermotx                            T      0675           41.1375        2528.64                           505.73
53853    Prostatic water thermother                       T      0162           23.8700        1467.24                           293.45
53899    Urology surgery procedure                CH      T      0126            1.0887          66.92             16.45          13.38
54000    Slitting of prepuce                              T      0166           18.3960     $1,130.77                          $226.15
54001    Slitting of prepuce                              T      0166           18.3960     $1,130.77                          $226.15
54015    Drain penis lesion                               T      0008           17.5086     $1,076.22                          $215.24
54050    Destruction, penis lesion(s)                     T      0013            1.0918        $67.11                           $13.42
54055    Destruction, penis lesion(s)                     T      0017           17.4423     $1,072.14         $227.84          $214.43
54056    Cryosurgery, penis lesion(s)                     T      0012            0.8432        $51.83          $11.18           $10.37
54057    Laser surg, penis lesion(s)                      T      0017           17.4423     $1,072.14         $227.84          $214.43
54060    Excision of penis lesion(s)                      T      0017           17.4423     $1,072.14         $227.84          $214.43
54065    Destruction, penis lesion(s)                     T      0695           20.4276     $1,255.64         $266.59          $251.13
54100    Biopsy of penis                                  T      0021           15.1024       $928.31         $219.48          $185.66
54105    Biopsy of penis                                  T      0022           20.0656     $1,233.39         $354.45          $246.68
54110    Treatment of penis lesion                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54111    Treat penis lesion, graft                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54112    Treat penis lesion, graft                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54115    Treatment of penis lesion                        T      0008           17.5086     $1,076.22                          $215.24
54120    Partial removal of penis                         T      0181           32.9873     $2,027.66         $621.82          $405.53
54125    Removal of penis                                 C
54130    Remove penis & nodes                             C
54135    Remove penis & nodes                             C
54150    Circumcision w/regionl block                     T      0180     20.5513             1263.25           304.87           252.65
54152    Circumcision                                     T      0180     20.5513
                                                                   Milliman                 $1,263.25         $304.87          $252.65
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 67 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
54160    Circumcision, neonate                            T      0180           20.5513     $1,263.25     $304.87    $252.65
54161    Circum 28 days or older                          T      0180           20.5513     $1,263.25     $304.87    $252.65
54162    Lysis penil circumic lesion                      T      0180           20.5513     $1,263.25     $304.87    $252.65
54163    Repair of circumcision                           T      0180           20.5513     $1,263.25     $304.87    $252.65
54164    Frenulotomy of penis                             T      0180           20.5513        1263.25      304.87     252.65
54200    Treatment of penis lesion                CH      T      0164            2.1393       $131.50                 $26.30
54205    Treatment of penis lesion                        T      0181           32.9873        2027.66      621.82     405.53
54220    Treatment of penis lesion                CH      T      0164            2.1393          131.5                   26.3
54230    Prepare penis study                              N
54231    Dynamic cavernosometry                           T      0165           18.1679     $1,116.74                          $223.35
54235    Penile injection                                 T      0164            2.1393          131.5                             26.3
54240    Penis study                              CH      T      0126            1.0887        $66.92             $16.45        $13.38
54250    Penis study                                      T      0164            2.1393       $131.50                           $26.30
54300    Revision of penis                                T      0181           32.9873        2027.66          621.82           405.53
54304    Revision of penis                                T      0181           32.9873     $2,027.66         $621.82          $405.53
54308    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54312    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54316    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54318    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54322    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54324    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54326    Reconstruction of urethra                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54328    Revise penis/urethra                             T      0181           32.9873     $2,027.66         $621.82          $405.53
54332    Revise penis/urethra                             C
54336    Revise penis/urethra                             C
54340    Secondary urethral surgery                       T      0181           32.9873     $2,027.66         $621.82          $405.53
54344    Secondary urethral surgery                       T      0181           32.9873     $2,027.66         $621.82          $405.53
54348    Secondary urethral surgery                       T      0181           32.9873     $2,027.66         $621.82          $405.53
54352    Reconstruct urethra/penis                        T      0181           32.9873     $2,027.66         $621.82          $405.53
54360    Penis plastic surgery                            T      0181           32.9873     $2,027.66         $621.82          $405.53
54380    Repair penis                                     T      0181           32.9873     $2,027.66         $621.82          $405.53
54385    Repair penis                                     T      0181           32.9873     $2,027.66         $621.82          $405.53
54390    Repair penis and bladder                         C
54400    Insert semi-rigid prosthesis                     S      0385           79.2092       4868.83                             973.77
54401    Insert self-contd prosthesis                     S      0386          137.3897       8445.07                            1689.01
54405    Insert multi-comp penis pros                     S      0386          137.3897       8445.07                            1689.01
54406    Remove muti-comp penis pros                      T      0181           32.9873     $2,027.66         $621.82           $405.53
54408    Repair multi-comp penis pros                     T      0181           32.9873     $2,027.66         $621.82           $405.53
54410    Remove/replace penis prosth                      S      0386          137.3897     $8,445.07                         $1,689.01
54411    Remov/replc penis pros, comp                     C
54415    Remove self-contd penis pros                     T      0181           32.9873     $2,027.66         $621.82           $405.53
54416    Remv/repl penis contain pros                     S      0386          137.3897     $8,445.07                         $1,689.01
54417    Remv/replc penis pros, compl                     C
54420    Revision of penis                                T      0181           32.9873     $2,027.66         $621.82          $405.53
54430    Revision of penis                                C
54435    Revision of penis                                T      0181     32.9873             2027.66           621.82           405.53
54440    Repair of penis                                  T      0181     32.9873           $2,027.66         $621.82          $405.53
54450    Preputial stretching                             T      0156       3.4079              209.48                             41.9
54500    Biopsy of testis                                 T      0037     10.2655                  631            228.76          126.2
54505    Biopsy of testis                                 T      0183     23.5310               1446.4                           289.28
54512    Excise lesion testis                             T      0183     23.5310               1446.4                           289.28
54520    Removal of testis                                T      0183     23.5310               1446.4                           289.28
54522    Orchiectomy, partial                             T      0183     23.5310
                                                                   Milliman                     1446.4                           289.28
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 68 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468             2007 CF
                                                                                                    National   Minimum
HCPCS/                                                                         Relative            Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment Copayment
54530    Removal of testis                                T      0154           29.2182   1795.98       464.85      359.2
54535    Extensive testis surgery                         C
54550    Exploration for testis                           T      0154           29.2182     1795.98              464.85          359.2
54560    Exploration for testis                           T      0183           23.5310      1446.4                             289.28
54600    Reduce testis torsion                            T      0183           23.5310      1446.4                             289.28
54620    Suspension of testis                             T      0183           23.5310      1446.4                             289.28
54640    Suspension of testis                             T      0154           29.2182     1795.98              464.85          359.2
54650    Orchiopexy (Fowler-Stephens)                     C
54660    Revision of testis                               T      0183           23.5310      1446.4                              289.28
54670    Repair testis injury                             T      0183           23.5310      1446.4                              289.28
54680    Relocation of testis(es)                         T      0183           23.5310      1446.4                              289.28
54690    Laparoscopy, orchiectomy                         T      0131           43.5488     2676.86             1001.89          535.37
54692    Laparoscopy, orchiopexy                          T      0132           70.5066      4333.9             1239.22          866.78
54699    Laparoscope proc, testis                         T      0130           32.1241      1974.6              659.53          394.92
54700    Drainage of scrotum                              T      0183           23.5310      1446.4                              289.28
54800    Biopsy of epididymis                             T      0004            2.0687    $127.16                              $25.43
54820    Exploration of epididymis                CH      D
54830    Remove epididymis lesion                         T      0183           23.5310   $1,446.40                           $289.28
54840    Remove epididymis lesion                         T      0183           23.5310   $1,446.40                           $289.28
54860    Removal of epididymis                            T      0183           23.5310       1446.4                            289.28
54861    Removal of epididymis                            T      0183           23.5310   $1,446.40                           $289.28
54865    Explore epididymis                       NI      T      0183           23.5310   $1,446.40                           $289.28
54900    Fusion of spermatic ducts                        T      0183           23.5310   $1,446.40                           $289.28
54901    Fusion of spermatic ducts                        T      0183           23.5310   $1,446.40                           $289.28
55000    Drainage of hydrocele                            T      0004            2.0687       127.16                             25.43
55040    Removal of hydrocele                             T      0154           29.2182      1795.98             464.85          359.2
55041    Removal of hydroceles                            T      0154           29.2182      1795.98             464.85          359.2
55060    Repair of hydrocele                              T      0183           23.5310       1446.4                            289.28
55100    Drainage of scrotum abscess              CH      T      0007           11.1535     $685.58                           $137.12
55110    Explore scrotum                                  T      0183           23.5310   $1,446.40                           $289.28
55120    Removal of scrotum lesion                        T      0183           23.5310   $1,446.40                           $289.28
55150    Removal of scrotum                               T      0183           23.5310   $1,446.40                           $289.28
55175    Revision of scrotum                              T      0183           23.5310   $1,446.40                           $289.28
55180    Revision of scrotum                              T      0183           23.5310   $1,446.40                           $289.28
55200    Incision of sperm duct                           T      0183           23.5310   $1,446.40                           $289.28
55250    Removal of sperm duct(s)                         T      0183           23.5310   $1,446.40                           $289.28
55300    Prepare, sperm duct x-ray                        N
55400    Repair of sperm duct                             T      0183           23.5310   $1,446.40                           $289.28
55450    Ligation of sperm duct                           T      0183           23.5310   $1,446.40                           $289.28
55500    Removal of hydrocele                             T      0183           23.5310   $1,446.40                           $289.28
55520    Removal of sperm cord lesion                     T      0183           23.5310   $1,446.40                           $289.28
55530    Revise spermatic cord veins                      T      0183           23.5310   $1,446.40                           $289.28
55535    Revise spermatic cord veins                      T      0154           29.2182   $1,795.98         $464.85           $359.20
55540    Revise hernia & sperm veins                      T      0154           29.2182   $1,795.98         $464.85           $359.20
55550    Laparo ligate spermatic vein                     T      0131           43.5488   $2,676.86       $1,001.89           $535.37
55559    Laparo proc, spermatic cord                      T      0130           32.1241       1974.6          659.53            394.92
55600    Incise sperm duct pouch                          T      0183           23.5310       1446.4                            289.28
55605    Incise sperm duct pouch                          C
55650    Remove sperm duct pouch                          C
55680    Remove sperm pouch lesion                        T      0183     23.5310         $1,446.40                           $289.28
55700    Biopsy of prostate                               T      0184       5.6262          $345.83             $96.27         $69.17
55705    Biopsy of prostate                               T      0184       5.6262          $345.83             $96.27         $69.17
55720    Drainage of prostate abscess                     T      0162     23.8700
                                                                   Milliman               $1,467.24                           $293.45
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 69 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                    National              Minimum
HCPCS/                                                                         Relative            Unadjusted             Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment              Copayment
55725    Drainage of prostate abscess                     T      0162           23.8700 $1,467.24                            $293.45
55801    Removal of prostate                              C
55810    Extensive prostate surgery                       C
55812    Extensive prostate surgery                       C
55815    Extensive prostate surgery                       C
55821    Removal of prostate                              C
55831    Removal of prostate                              C
55840    Extensive prostate surgery                       C
55842    Extensive prostate surgery                       C
55845    Extensive prostate surgery                       C
55859    Percut/needle insert, pros               CH      D
55860    Surgical exposure, prostate                      T      0165           18.1679     1116.74                            223.35
55862    Extensive prostate surgery                       C
55865    Extensive prostate surgery                       C
55866    Laparo radical prostatectomy                     C
55870    Electroejaculation                               T      0197            4.0007       245.92                             49.18
55873    Cryoablate prostate                              T      0674          108.7566   $6,685.05                         $1,337.01
55875    Transperi needle place, pros             NI      T      0163           34.9261   $2,146.84                           $429.37
55876    Place rt device/marker, pros             NI      T      0156            3.4079     $209.48                            $41.90
55899    Genital surgery procedure                CH      T      0126            1.0887        66.92             16.45           13.38
55970    Sex transformation, M to F                       E
55980    Sex transformation, F to M                       E
56405    I & D of vulva/perineum                          T      0189            2.8966       178.05                            35.61
56420    Drainage of gland abscess                CH      T      0188            1.2900        79.29                            15.86
56440    Surgery for vulva lesion                         T      0194           20.5081      1260.59            397.84         252.12
56441    Lysis of labial lesion(s)                        T      0193           14.8489       912.73                           182.55
56442    Hymenotomy                               NI      T      0193           14.8489       912.73                           182.55
56501    Destroy, vulva lesions, sim                      T      0017           17.4423   $1,072.14         $227.84          $214.43
56515    Destroy vulva lesion/s compl                     T      0695           20.4276   $1,255.64         $266.59          $251.13
56605    Biopsy of vulva/perineum                         T      0019            4.0919     $251.52          $71.87           $50.30
56606    Biopsy of vulva/perineum                         T      0019            4.0919     $251.52          $71.87           $50.30
56620    Partial removal of vulva                         T      0195           28.5095   $1,752.42         $483.80          $350.48
56625    Complete removal of vulva                        T      0195           28.5095   $1,752.42         $483.80          $350.48
56630    Extensive vulva surgery                          C
56631    Extensive vulva surgery                          C
56632    Extensive vulva surgery                          C
56633    Extensive vulva surgery                          C
56634    Extensive vulva surgery                          C
56637    Extensive vulva surgery                          C
56640    Extensive vulva surgery                          C
56700    Partial removal of hymen                         T      0194           20.5081     1260.59             397.84         252.12
56720    Incision of hymen                        CH      D
56740    Remove vagina gland lesion                       T      0194     20.5081            1260.59            397.84         252.12
56800    Repair of vagina                                 T      0194     20.5081            1260.59            397.84         252.12
56805    Repair clitoris                                  T      0193     14.8489             912.73                           182.55
56810    Repair of perineum                               T      0194     20.5081            1260.59            397.84         252.12
56820    Exam of vulva w/scope                            T      0188       1.2900             79.29                            15.86
56821    Exam/biopsy of vulva w/scope                     T      0189       2.8966          $178.05                           $35.61
57000    Exploration of vagina                            T      0193     14.8489           $912.73                          $182.55
57010    Drainage of pelvic abscess                       T      0193     14.8489           $912.73                          $182.55
57020    Drainage of pelvic fluid                         T      0192       6.6592          $409.33                           $81.87
57022    I & d vaginal hematoma, pp                       T      0007     11.1535           $685.58                          $137.12
57023    I & d vag hematoma, non-ob                       T      0008     17.5086
                                                                   Milliman               $1,076.22                          $215.24
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                       Page 70 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
57061    Destroy vag lesions, simple                      T      0194           20.5081       1260.59       397.84     252.12
57065    Destroy vag lesions, complex                     T      0194           20.5081       1260.59       397.84     252.12
57100    Biopsy of vagina                                 T      0192            6.6592         409.33                  81.87
57105    Biopsy of vagina                                 T      0194           20.5081     $1,260.59     $397.84    $252.12
57106    Remove vagina wall, partial                      T      0194           20.5081       1260.59       397.84     252.12
57107    Remove vagina tissue, part                       T      0195           28.5095     $1,752.42     $483.80    $350.48
57109    Vaginectomy partial w/nodes                      T      0195           28.5095     $1,752.42     $483.80    $350.48
57110    Remove vagina wall, complete                     C
57111    Remove vagina tissue, compl                      C
57112    Vaginectomy w/nodes, compl                       C
57120    Closure of vagina                                T      0195           28.5095       1752.42              483.8         350.48
57130    Remove vagina lesion                             T      0194           20.5081       1260.59             397.84         252.12
57135    Remove vagina lesion                             T      0194           20.5081       1260.59             397.84         252.12
57150    Treat vagina infection                           T      0191            0.1468           9.02              2.55            1.8
57155    Insert uteri tandems/ovoids                      T      0192            6.6592         409.33                            81.87
57160    Insert pessary/other device                      T      0188            1.2900        $79.29                           $15.86
57170    Fitting of diaphragm/cap                         T      0191            0.1468           9.02              2.55            1.8
57180    Treat vaginal bleeding                           T      0189            2.8966         178.05                            35.61
57200    Repair of vagina                                 T      0194           20.5081       1260.59           397.84           252.12
57210    Repair vagina/perineum                           T      0194           20.5081       1260.59           397.84           252.12
57220    Revision of urethra                              T      0202           42.9896     $2,642.48         $981.50          $528.50
57230    Repair of urethral lesion                        T      0195           28.5095     $1,752.42         $483.80          $350.48
57240    Repair bladder & vagina                          T      0195           28.5095     $1,752.42         $483.80          $350.48
57250    Repair rectum & vagina                           T      0195           28.5095       1752.42            483.8           350.48
57260    Repair of vagina                                 T      0195           28.5095     $1,752.42         $483.80          $350.48
57265    Extensive repair of vagina                       T      0202           42.9896     $2,642.48         $981.50          $528.50
57267    Insert mesh/pelvic flr addon             CH      T      0195           28.5095       1752.42            483.8           350.48
57268    Repair of bowel bulge                            T      0195           28.5095       1752.42            483.8           350.48
57270    Repair of bowel pouch                            C
57280    Suspension of vagina                             C
57282    Colpopexy, extraperitoneal               CH      T      0202           42.9896       2642.48            981.5            528.5
57283    Colpopexy, intraperitoneal               CH      T      0202           42.9896       2642.48            981.5            528.5
57284    Repair paravaginal defect                        T      0202           42.9896     $2,642.48         $981.50          $528.50
57287    Revise/remove sling repair               CH      T      0195           28.5095     $1,752.42         $483.80          $350.48
57288    Repair bladder defect                            T      0202           42.9896     $2,642.48         $981.50          $528.50
57289    Repair bladder & vagina                          T      0195           28.5095     $1,752.42         $483.80          $350.48
57291    Construction of vagina                           T      0195           28.5095     $1,752.42         $483.80          $350.48
57292    Construct vagina with graft              CH      T      0195           28.5095     $1,752.42         $483.80          $350.48
57295    Change vaginal graft                             T      0194           20.5081     $1,260.59         $397.84          $252.12
57296    Revise vag graft, open abd               NI      C
57300    Repair rectum-vagina fistula                     T      0195           28.5095     $1,752.42         $483.80          $350.48
57305    Repair rectum-vagina fistula                     C
57307    Fistula repair & colostomy                       C
57308    Fistula repair, transperine                      C
57310    Repair urethrovaginal lesion                     T      0202           42.9896     $2,642.48         $981.50          $528.50
57311    Repair urethrovaginal lesion                     C
57320    Repair bladder-vagina lesion                     T      0195     28.5095           $1,752.42              483.8       $350.48
57330    Repair bladder-vagina lesion                     T      0195     28.5095              1752.42             483.8         350.48
57335    Repair vagina                            CH      T      0195     28.5095           $1,752.42              483.8       $350.48
57400    Dilation of vagina                               T      0194     20.5081              1260.59            397.84         252.12
57410    Pelvic examination                               T      0193     14.8489               912.73                           182.55
57415    Remove vaginal foreign body                      T      0194     20.5081           $1,260.59         $397.84          $252.12
57420    Exam of vagina w/scope                           T        Milliman 2.8966
                                                                 0189                         $178.05                           $35.61
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 71 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
57421    Exam/biopsy of vag w/scope                       T      0189            2.8966       $178.05                 $35.61
57425    Laparoscopy, surg, colpopexy                     T      0130           32.1241         1974.6      659.53     394.92
57452    Exam of cervix w/scope                   CH      T      0188            1.2900          79.29                  15.86
57454    Bx/curett of cervix w/scope                      T      0189            2.8966       $178.05                 $35.61
57455    Biopsy of cervix w/scope                         T      0189            2.8966         178.05                  35.61
57456    Endocerv curettage w/scope                       T      0189            2.8966         178.05                  35.61
57460    Bx of cervix w/scope, leep                       T      0193           14.8489         912.73                 182.55
57461    Conz of cervix w/scope, leep                     T      0194           20.5081        1260.59      397.84     252.12
57500    Biopsy of cervix                         CH      T      0189            2.8966         178.05                  35.61
57505    Endocervical curettage                           T      0189            2.8966         178.05                  35.61
57510    Cauterization of cervix                          T      0193           14.8489         912.73                 182.55
57511    Cryocautery of cervix                    CH      T      0188            1.2900          79.29                  15.86
57513    Laser surgery of cervix                          T      0193           14.8489       $912.73                $182.55
57520    Conization of cervix                             T      0194           20.5081     $1,260.59     $397.84    $252.12
57522    Conization of cervix                             T      0195           28.5095     $1,752.42     $483.80    $350.48
57530    Removal of cervix                                T      0195           28.5095     $1,752.42     $483.80    $350.48
57531    Removal of cervix, radical                       C
57540    Removal of residual cervix                       C
57545    Remove cervix/repair pelvis                      C
57550    Removal of residual cervix                       T      0195           28.5095     $1,752.42         $483.80          $350.48
57555    Remove cervix/repair vagina                      T      0195           28.5095     $1,752.42         $483.80          $350.48
57556    Remove cervix, repair bowel                      T      0202           42.9896       2642.48            981.5            528.5
57558    D&c of cervical stump                    NI      T      0196           17.7499       1091.05           338.23           218.21
57700    Revision of cervix                               T      0194           20.5081       1260.59           397.84           252.12
57720    Revision of cervix                               T      0194           20.5081       1260.59           397.84           252.12
57800    Dilation of cervical canal                       T      0193           14.8489         912.73                           182.55
57820    D & c of residual cervix                 CH      D
58100    Biopsy of uterus lining                          T      0188            1.2900         79.29                             15.86
58110    Bx done w/colposcopy add-on                      T      0188            1.2900         79.29                             15.86
58120    Dilation and curettage                           T      0196           17.7499       1091.05             338.23         218.21
58140    Myomectomy abdom method                          C
58145    Myomectomy vag method                            T      0195           28.5095     $1,752.42         $483.80          $350.48
58146    Myomectomy abdom complex                         C
58150    Total hysterectomy                               C
58152    Total hysterectomy                               C
58180    Partial hysterectomy                             C
58200    Extensive hysterectomy                           C
58210    Extensive hysterectomy                           C
58240    Removal of pelvis contents                       C
58260    Vaginal hysterectomy                     CH      T      0195           28.5095       1752.42              483.8         350.48
58262    Vag hyst including t/o                   CH      T      0195           28.5095       1752.42              483.8         350.48
58263    Vag hyst w/t/o & vag repair              CH      T      0195           28.5095       1752.42              483.8         350.48
58267    Vag hyst w/urinary repair                        C
58270    Vag hyst w/enterocele repair             CH      T      0195           28.5095       1752.42              483.8         350.48
58275    Hysterectomy/revise vagina                       C
58280    Hysterectomy/revise vagina                       C
58285    Extensive hysterectomy                           C
58290    Vag hyst complex                         CH      T      0202           42.9896       2642.48              981.5              528.5
58291    Vag hyst incl t/o, complex               CH      T      0202           42.9896       2642.48              981.5              528.5
58292    Vag hyst t/o & repair, compl             CH      T      0202           42.9896       2642.48              981.5              528.5
58293    Vag hyst w/uro repair, compl                     C
58294    Vag hyst w/enterocele, compl             CH      T      0202           42.9896       2642.48              981.5              528.5
58300    Insert intrauterine device                       E        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 72 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment            Copayment
58301    Remove intrauterine device               CH      T      0188            1.2900         79.29                             15.86
58321    Artificial insemination                          T      0197            4.0007        245.92                             49.18
58322    Artificial insemination                          T      0197            4.0007        245.92                             49.18
58323    Sperm washing                                    T      0197            4.0007        245.92                             49.18
58340    Catheter for hysterography                       N
58345    Reopen fallopian tube                            T      0193           14.8489        912.73                            182.55
58346    Insert heyman uteri capsule                      T      0193           14.8489        912.73                            182.55
58350    Reopen fallopian tube                            T      0195           28.5095       1752.42              483.8         350.48
58353    Endometr ablate, thermal                         T      0195           28.5095       1752.42              483.8         350.48
58356    Endometrial cryoablation                         T      0202           42.9896       2642.48              981.5          528.5
58400    Suspension of uterus                             C
58410    Suspension of uterus                             C
58520    Repair of ruptured uterus                        C
58540    Revision of uterus                               C
58541    Lsh, uterus 250 g or less                NI      T      0131           43.5488       2676.86            1001.89         535.37
58542    Lsh w/t/o ut 250 g or less               NI      T      0131           43.5488       2676.86            1001.89         535.37
58543    Lsh uterus above 250 g                   NI      T      0131           43.5488       2676.86            1001.89         535.37
58544    Lsh w/t/o uterus above 250 g             NI      T      0131           43.5488       2676.86            1001.89         535.37
58545    Laparoscopic myomectomy                          T      0130           32.1241        1974.6             659.53         394.92
58546    Laparo-myomectomy, complex                       T      0131           43.5488       2676.86            1001.89         535.37
58548    Lap radical hyst                         NI      C
58550    Laparo-asst vag hysterectomy                     T      0132           70.5066        4333.9            1239.22         866.78
58552    Laparo-vag hyst incl t/o                         T      0131           43.5488       2676.86            1001.89         535.37
58553    Laparo-vag hyst, complex                         T      0131           43.5488       2676.86            1001.89         535.37
58554    Laparo-vag hyst w/t/o, compl                     T      0131           43.5488       2676.86            1001.89         535.37
58555    Hysteroscopy, dx, sep proc                       T      0190           21.3586       1312.87             424.28         262.57
58558    Hysteroscopy, biopsy                             T      0190           21.3586       1312.87             424.28         262.57
58559    Hysteroscopy, lysis                              T      0190           21.3586       1312.87             424.28         262.57
58560    Hysteroscopy, resect septum                      T      0387           34.0155       2090.86             655.55         418.17
58561    Hysteroscopy, remove myoma                       T      0387           34.0155       2090.86             655.55         418.17
58562    Hysteroscopy, remove fb                          T      0190           21.3586       1312.87             424.28         262.57
58563    Hysteroscopy, ablation                           T      0387           34.0155       2090.86             655.55         418.17
58565    Hysteroscopy, sterilization                      T      0202           42.9896       2642.48              981.5          528.5
58578    Laparo proc, uterus                              T      0130           32.1241        1974.6             659.53         394.92
58579    Hysteroscope procedure                           T      0190           21.3586       1312.87             424.28         262.57
58600    Division of fallopian tube                       T      0195           28.5095       1752.42              483.8         350.48
58605    Division of fallopian tube                       C
58611    Ligate oviduct(s) add-on                         C
58615    Occlude fallopian tube(s)                        T      0194           20.5081       1260.59             397.84         252.12
58660    Laparoscopy, lysis                               T      0131           43.5488       2676.86            1001.89         535.37
58661    Laparoscopy, remove adnexa                       T      0131           43.5488       2676.86            1001.89         535.37
58662    Laparoscopy, excise lesions                      T      0131           43.5488       2676.86            1001.89         535.37
58670    Laparoscopy, tubal cautery                       T      0131           43.5488       2676.86            1001.89         535.37
58671    Laparoscopy, tubal block                         T      0131           43.5488       2676.86            1001.89         535.37
58672    Laparoscopy, fimbrioplasty                       T      0131           43.5488       2676.86            1001.89         535.37
58673    Laparoscopy, salpingostomy                       T      0131           43.5488       2676.86            1001.89         535.37
58679    Laparo proc, oviduct-ovary                       T      0130           32.1241        1974.6             659.53         394.92
58700    Removal of fallopian tube                        C
58720    Removal of ovary/tube(s)                         C
58740    Revise fallopian tube(s)                         C
58750    Repair oviduct                                   C
58752    Revise ovarian tube(s)                           C
58760    Remove tubal obstruction                         C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 73 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468             2007 CF
                                                                                                    National   Minimum
HCPCS/                                                                         Relative            Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment Copayment
58770    Create new tubal opening                         T      0195           28.5095   1752.42        483.8     350.48
58800    Drainage of ovarian cyst(s)                      T      0193           14.8489    912.73                  182.55
58805    Drainage of ovarian cyst(s)                      C
58820    Drain ovary abscess, open                        T      0195           28.5095     1752.42               483.8         350.48
58822    Drain ovary abscess, percut                      C
58823    Drain pelvic abscess, percut                     T      0193           14.8489      912.73                             182.55
58825    Transposition, ovary(s)                          C
58900    Biopsy of ovary(s)                               T      0193           14.8489      912.73                             182.55
58920    Partial removal of ovary(s)                      T      0195           28.5095     1752.42               483.8         350.48
58925    Removal of ovarian cyst(s)                       T      0195           28.5095     1752.42               483.8         350.48
58940    Removal of ovary(s)                              C
58943    Removal of ovary(s)                              C
58950    Resect ovarian malignancy                        C
58951    Resect ovarian malignancy                        C
58952    Resect ovarian malignancy                        C
58953    Tah, rad dissect for debulk                      C
58954    Tah rad debulk/lymph remove                      C
58956    Bso, omentectomy w/tah                           C
58957    Resect recurrent gyn mal                 NI      C
58958    Resect recur gyn mal w/lym               NI      C
58960    Exploration of abdomen                           C
58970    Retrieval of oocyte                              T      0197            4.0007      245.92                               49.18
58974    Transfer of embryo                               T      0197            4.0007      245.92                               49.18
58976    Transfer of embryo                               T      0197            4.0007    $245.92                              $49.18
58999    Genital surgery procedure                        T      0191            0.1468        9.02                2.55             1.8
59000    Amniocentesis, diagnostic                        T      0198            1.4222     $87.42                32.19         $17.48
59001    Amniocentesis, therapeutic                       T      0192            6.6592      409.33                               81.87
59012    Fetal cord puncture,prenatal                     T      0198            1.4222       87.42               32.19           17.48
59015    Chorion biopsy                                   T      0198            1.4222       87.42               32.19           17.48
59020    Fetal contract stress test               CH      T      0189            2.8966      178.05                               35.61
59025    Fetal non-stress test                            T      0198            1.4222       87.42               32.19           17.48
59030    Fetal scalp blood sample                         T      0198            1.4222       87.42               32.19           17.48
59050    Fetal monitor w/report                           M
59051    Fetal monitor/interpret only                     B
59070    Transabdom amnioinfus w/us                       T      0198            1.4222       87.42               32.19          17.48
59072    Umbilical cord occlud w/us                       T      0198            1.4222       87.42               32.19          17.48
59074    Fetal fluid drainage w/us                        T      0198            1.4222       87.42               32.19          17.48
59076    Fetal shunt placement, w/us                      T      0198            1.4222       87.42               32.19          17.48
59100    Remove uterus lesion                             T      0195           28.5095     1752.42               483.8         350.48
59120    Treat ectopic pregnancy                          C
59121    Treat ectopic pregnancy                          C
59130    Treat ectopic pregnancy                          C
59135    Treat ectopic pregnancy                          C
59136    Treat ectopic pregnancy                          C
59140    Treat ectopic pregnancy                          C
59150    Treat ectopic pregnancy                          T      0131           43.5488      2676.86            1001.89         535.37
59151    Treat ectopic pregnancy                          T      0131           43.5488      2676.86            1001.89         535.37
59160    D& c after delivery                              T      0196           17.7499   $1,091.05              338.23       $218.21
59200    Insert cervical dilator                          T      0189            2.8966     $178.05                            $35.61
59300    Episiotomy or vaginal repair                     T      0193           14.8489       912.73                            182.55
59320    Revision of cervix                               T      0194           20.5081   $1,260.59         $397.84           $252.12
59325    Revision of cervix                               C
59350    Repair of uterus                                 C        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment             Copayment
59400    Obstetrical care                                 B
59409    Obstetrical care                                 T      0194           20.5081       1260.59             397.84          252.12
59410    Obstetrical care                                 B
59412    Antepartum manipulation                          T      0700            2.3864       $146.69                            $29.34
59414    Deliver placenta                                 T      0193           14.8489       $912.73                           $182.55
59425    Antepartum care only                             B
59426    Antepartum care only                             B
59430    Care after delivery                              B
59510    Cesarean delivery                                B
59514    Cesarean delivery only                           C
59515    Cesarean delivery                                B
59525    Remove uterus after cesarean                     C
59610    Vbac delivery                                    B
59612    Vbac delivery only                               T      0194           20.5081       1260.59             397.84          252.12
59614    Vbac care after delivery                         B
59618    Attempted vbac delivery                          B
59620    Attempted vbac delivery only                     C
59622    Attempted vbac after care                        B
59812    Treatment of miscarriage                         T      0201           18.5201       1138.39             329.65          227.68
59820    Care of miscarriage                              T      0201           18.5201       1138.39             329.65          227.68
59821    Treatment of miscarriage                         T      0201           18.5201       1138.39             329.65          227.68
59830    Treat uterus infection                           C
59840    Abortion                                         T      0200           16.9328       1040.83             243.36          208.17
59841    Abortion                                         T      0200           16.9328       1040.83             243.36          208.17
59850    Abortion                                         C
59851    Abortion                                         C
59852    Abortion                                         C
59855    Abortion                                         C
59856    Abortion                                         C
59857    Abortion                                         C
59866    Abortion (mpr)                                   T      0198            1.4222          87.42              32.19          17.48
59870    Evacuate mole of uterus                          T      0201           18.5201        1138.39             329.65         227.68
59871    Remove cerclage suture                           T      0194           20.5081        1260.59             397.84         252.12
59897    Fetal invas px w/us                              T      0198            1.4222        $87.42             $32.19         $17.48
59898    Laparo proc, ob care/deliver                     T      0130           32.1241         1974.6             659.53         394.92
59899    Maternity care procedure                         T      0198            1.4222          87.42              32.19          17.48
60000    Drain thyroid/tongue cyst                        T      0252            7.5511         464.15             109.16          92.83
60001    Aspirate/inject thyriod cyst                     T      0004            2.0687         127.16                             25.43
60100    Biopsy of thyroid                                T      0004            2.0687       $127.16                            $25.43
60200    Remove thyroid lesion                            T      0114           37.7224     $2,318.72         $467.95           $463.74
60210    Partial thyroid excision                         T      0114           37.7224     $2,318.72         $467.95           $463.74
60212    Partial thyroid excision                         T      0114           37.7224        2318.72          467.95            463.74
60220    Partial removal of thyroid                       T      0114           37.7224        2318.72          467.95            463.74
60225    Partial removal of thyroid                       T      0114           37.7224     $2,318.72         $467.95           $463.74
60240    Removal of thyroid                               T      0114           37.7224     $2,318.72         $467.95           $463.74
60252    Removal of thyroid                               T      0256           38.1991     $2,348.02                           $469.60
60254    Extensive thyroid surgery                        C
60260    Repeat thyroid surgery                           T      0256           38.1991     $2,348.02                           $469.60
60270    Removal of thyroid                               C
60271    Removal of thyroid                               C
60280    Remove thyroid duct lesion                       T      0114     37.7224           $2,318.72         $467.95           $463.74
60281    Remove thyroid duct lesion                       T      0114     37.7224           $2,318.72         $467.95           $463.74
60500    Explore parathyroid glands                       T      0256     38.1991
                                                                   Milliman                 $2,348.02                           $469.60
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                          Page 75 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                    National             Minimum
HCPCS/                                                                         Relative            Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment             Copayment
60502    Re-explore parathyroids                  CH      T      0256           38.1991   2348.02                              469.6
60505    Explore parathyroid glands                       C
60512    Autotransplant parathyroid                       T      0022           20.0656     1233.39            354.45         246.68
60520    Removal of thymus gland                  CH      T      0256           38.1991     2348.02                            469.6
60521    Removal of thymus gland                          C
60522    Removal of thymus gland                          C
60540    Explore adrenal gland                            C
60545    Explore adrenal gland                            C
60600    Remove carotid body lesion                       C
60605    Remove carotid body lesion                       C
60650    Laparoscopy adrenalectomy                        C
60659    Laparo proc, endocrine                           T      0130           32.1241   $1,974.60          659.53         $394.92
60699    Endocrine surgery procedure                      T      0114           37.7224   $2,318.72        $467.95          $463.74
61000    Remove cranial cavity fluid                      T      0212            2.9907     $183.83           65.96          $36.77
61001    Remove cranial cavity fluid                      T      0212            2.9907     $183.83           65.96          $36.77
61020    Remove brain cavity fluid                        T      0212            2.9907     $183.83           65.96          $36.77
61026    Injection into brain canal                       T      0212            2.9907     $183.83         $65.96           $36.77
61050    Remove brain canal fluid                         T      0212            2.9907     $183.83         $65.96           $36.77
61055    Injection into brain canal                       T      0212            2.9907     $183.83         $65.96           $36.77
61070    Brain canal shunt procedure                      T      0212            2.9907     $183.83           65.96          $36.77
61105    Twist drill hole                                 C
61107    Drill skull for implantation                     C
61108    Drill skull for drainage                         C
61120    Burr hole for puncture                           C
61140    Pierce skull for biopsy                          C
61150    Pierce skull for drainage                        C
61151    Pierce skull for drainage                        C
61154    Pierce skull & remove clot                       C
61156    Pierce skull for drainage                        C
61210    Pierce skull, implant device                     C
61215    Insert brain-fluid device                        T      0224           47.0342   $2,891.10                         $578.22
61250    Pierce skull & explore                           C
61253    Pierce skull & explore                           C
61304    Open skull for exploration                       C
61305    Open skull for exploration                       C
61312    Open skull for drainage                          C
61313    Open skull for drainage                          C
61314    Open skull for drainage                          C
61315    Open skull for drainage                          C
61316    Implt cran bone flap to abdo                     C
61320    Open skull for drainage                          C
61321    Open skull for drainage                          C
61322    Decompressive craniotomy                         C
61323    Decompressive lobectomy                          C
61330    Decompress eye socket                            T      0256           38.1991     2348.02                                469.6
61332    Explore/biopsy eye socket                        C
61333    Explore orbit/remove lesion                      C
61334    Explore orbit/remove object                      T      0256           38.1991     2348.02                                469.6
61340    Subtemporal decompression                        C
61343    Incise skull (press relief)                      C
61345    Relieve cranial pressure                         C
61440    Incise skull for surgery                         C
61450    Incise skull for surgery                         C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 76 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
61458    Incise skull for brain wound                     C
61460    Incise skull for surgery                         C
61470    Incise skull for surgery                         C
61480    Incise skull for surgery                         C
61490    Incise skull for surgery                         C
61500    Removal of skull lesion                          C
61501    Remove infected skull bone                       C
61510    Removal of brain lesion                          C
61512    Remove brain lining lesion                       C
61514    Removal of brain abscess                         C
61516    Removal of brain lesion                          C
61517    Implt brain chemotx add-on                       C
61518    Removal of brain lesion                          C
61519    Remove brain lining lesion                       C
61520    Removal of brain lesion                          C
61521    Removal of brain lesion                          C
61522    Removal of brain abscess                         C
61524    Removal of brain lesion                          C
61526    Removal of brain lesion                          C
61530    Removal of brain lesion                          C
61531    Implant brain electrodes                         C
61533    Implant brain electrodes                         C
61534    Removal of brain lesion                          C
61535    Remove brain electrodes                          C
61536    Removal of brain lesion                          C
61537    Removal of brain tissue                          C
61538    Removal of brain tissue                          C
61539    Removal of brain tissue                          C
61540    Removal of brain tissue                          C
61541    Incision of brain tissue                         C
61542    Removal of brain tissue                          C
61543    Removal of brain tissue                          C
61544    Remove & treat brain lesion                      C
61545    Excision of brain tumor                          C
61546    Removal of pituitary gland                       C
61548    Removal of pituitary gland                       C
61550    Release of skull seams                           C
61552    Release of skull seams                           C
61556    Incise skull/sutures                             C
61557    Incise skull/sutures                             C
61558    Excision of skull/sutures                        C
61559    Excision of skull/sutures                        C
61563    Excision of skull tumor                          C
61564    Excision of skull tumor                          C
61566    Removal of brain tissue                          C
61567    Incision of brain tissue                         C
61570    Remove foreign body, brain                       C
61571    Incise skull for brain wound                     C
61575    Skull base/brainstem surgery                     C
61576    Skull base/brainstem surgery                     C
61580    Craniofacial approach, skull                     C
61581    Craniofacial approach, skull                     C
61582    Craniofacial approach, skull                     C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                  Page 77 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
61583    Craniofacial approach, skull                     C
61584    Orbitocranial approach/skull                     C
61585    Orbitocranial approach/skull                     C
61586    Resect nasopharynx, skull                        C
61590    Infratemporal approach/skull                     C
61591    Infratemporal approach/skull                     C
61592    Orbitocranial approach/skull                     C
61595    Transtemporal approach/skull                     C
61596    Transcochlear approach/skull                     C
61597    Transcondylar approach/skull                     C
61598    Transpetrosal approach/skull                     C
61600    Resect/excise cranial lesion                     C
61601    Resect/excise cranial lesion                     C
61605    Resect/excise cranial lesion                     C
61606    Resect/excise cranial lesion                     C
61607    Resect/excise cranial lesion                     C
61608    Resect/excise cranial lesion                     C
61609    Transect artery, sinus                           C
61610    Transect artery, sinus                           C
61611    Transect artery, sinus                           C
61612    Transect artery, sinus                           C
61613    Remove aneurysm, sinus                           C
61615    Resect/excise lesion, skull                      C
61616    Resect/excise lesion, skull                      C
61618    Repair dura                                      C
61619    Repair dura                                      C
61623    Endovasc tempory vessel occl                     T      0081           42.9360     $2,639.19                         $527.84
61624    Transcath occlusion, cns                         C
61626    Transcath occlusion, non-cns                     T      0081           42.9360     $2,639.19                         $527.84
61630    Intracranial angioplasty                         E
61635    Intracran angioplsty w/stent                     E
61640    Dilate ic vasospasm, init                        E
61641    Dilate ic vasospasm add-on                       E
61642    Dilate ic vasospasm add-on                       E
61680    Intracranial vessel surgery                      C
61682    Intracranial vessel surgery                      C
61684    Intracranial vessel surgery                      C
61686    Intracranial vessel surgery                      C
61690    Intracranial vessel surgery                      C
61692    Intracranial vessel surgery                      C
61697    Brain aneurysm repr, complx                      C
61698    Brain aneurysm repr, complx                      C
61700    Brain aneurysm repr, simple                      C
61702    Inner skull vessel surgery                       C
61703    Clamp neck artery                                C
61705    Revise circulation to head                       C
61708    Revise circulation to head                       C
61710    Revise circulation to head                       C
61711    Fusion of skull arteries                         C
61720    Incise skull/brain surgery               CH      T      0221           33.1520       2037.79            463.62         407.56
61735    Incise skull/brain surgery                       C
61750    Incise skull/brain biopsy                        C
61751    Brain biopsy w/ct/mr guide                       C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 78 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
61760    Implant brain electrodes                         C
61770    Incise skull for treatment                       C
61790    Treat trigeminal nerve                           T      0220           17.8499     $1,097.20                          $219.44
61791    Treat trigeminal tract                           T      0206            5.7253       $351.92              75.55        $70.38
61793    Focus radiation beam                             B
61795    Brain surgery using computer                     S      0302            4.9138       $302.04             105.94         $60.41
61850    Implant neuroelectrodes                          C
61860    Implant neuroelectrodes                          C
61863    Implant neuroelectrode                           C
61864    Implant neuroelectrde, addl                      C
61867    Implant neuroelectrode                           C
61868    Implant neuroelectrde, add'l                     C
61870    Implant neuroelectrodes                          C
61875    Implant neuroelectrodes                          C
61880    Revise/remove neuroelectrode                     T      0687           17.8334     $1,096.18         $438.47           $219.24
61885    Insrt/redo neurostim 1 array                     S      0039          187.3821    $11,518.00                         $2,303.60
61886    Implant neurostim arrays                         T      0315          242.9363    $14,932.81                         $2,986.56
61888    Revise/remove neuroreceiver                      T      0688           35.5702     $2,186.43         $874.57           $437.29
62000    Treat skull fracture                     CH      T      0254           23.3299     $1,434.04         $321.35           $286.81
62005    Treat skull fracture                             C
62010    Treatment of head injury                         C
62100    Repair brain fluid leakage                       C
62115    Reduction of skull defect                        C
62116    Reduction of skull defect                        C
62117    Reduction of skull defect                        C
62120    Repair skull cavity lesion                       C
62121    Incise skull repair                              C
62140    Repair of skull defect                           C
62141    Repair of skull defect                           C
62142    Remove skull plate/flap                          C
62143    Replace skull plate/flap                         C
62145    Repair of skull & brain                          C
62146    Repair of skull with graft                       C
62147    Repair of skull with graft                       C
62148    Retr bone flap to fix skull                      C
62160    Neuroendoscopy add-on                            T      0122            7.4800       $459.78                            $91.96
62161    Dissect brain w/scope                            C
62162    Remove colloid cyst w/scope                      C
62163    Neuroendoscopy w/fb removal                      C
62164    Remove brain tumor w/scope                       C
62165    Remove pituit tumor w/scope                      C
62180    Establish brain cavity shunt                     C
62190    Establish brain cavity shunt                     C
62192    Establish brain cavity shunt                     C
62194    Replace/irrigate catheter                        T      0427           11.6575       $716.56                          $143.31
62200    Establish brain cavity shunt                     C
62201    Brain cavity shunt w/scope                       C
62220    Establish brain cavity shunt                     C
62223    Establish brain cavity shunt                     C
62225    Replace/irrigate catheter                        T      0427           11.6575         716.56                            143.31
62230    Replace/revise brain shunt                       T      0224           47.0342         2891.1                            578.22
62252    Csf shunt reprogram                              S      0691            2.8942       $177.90              60.61         $35.58
62256    Remove brain cavity shunt                        C        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 79 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment             Copayment
62258    Replace brain cavity shunt                       C
62263    Epidural lysis mult sessions                     T      0203           12.1702       $748.08              240.33       $149.62
62264    Epidural lysis on single day                     T      0203           12.1702       $748.08              240.33       $149.62
62268    Drain spinal cord cyst                           T      0212            2.9907       $183.83               65.96        $36.77
62269    Needle biopsy, spinal cord                       T      0685            6.1384       $377.32              115.47        $75.46
62270    Spinal fluid tap, diagnostic                     T      0204            2.2614       $139.00               40.13        $27.80
62272    Drain cerebro spinal fluid                       T      0204            2.2614       $139.00             $40.13         $27.80
62273    Inject epidural patch                            T      0206            5.7253       $351.92               75.55        $70.38
62280    Treat spinal cord lesion                         T      0207            6.3603       $390.95               86.92        $78.19
62281    Treat spinal cord lesion                         T      0207            6.3603       $390.95               86.92        $78.19
62282    Treat spinal canal lesion                        T      0207            6.3603       $390.95             $86.92         $78.19
62284    Injection for myelogram                          N
62287    Percutaneous diskectomy                          T      0221           33.1520     $2,037.79             463.62        $407.56
62290    Inject for spine disk x-ray                      N
62291    Inject for spine disk x-ray                      N
62292    Injection into disk lesion                       T      0212            2.9907         183.83              65.96           36.77
62294    Injection into spinal artery                     T      0212            2.9907       $183.83               65.96         $36.77
62310    Inject spine c/t                                 T      0207            6.3603       $390.95               86.92         $78.19
62311    Inject spine l/s (cd)                            T      0207            6.3603       $390.95               86.92         $78.19
62318    Inject spine w/cath, c/t                         T      0207            6.3603       $390.95               86.92         $78.19
62319    Inject spine w/cath l/s (cd)                     T      0207            6.3603       $390.95             $86.92          $78.19
62350    Implant spinal canal cath                        T      0223           30.8394     $1,895.64                            $379.13
62351    Implant spinal canal cath                        T      0208           44.1489     $2,713.74                            $542.75
62355    Remove spinal canal catheter                     T      0203           12.1702       $748.08         $240.33            $149.62
62360    Insert spine infusion device                     T      0226          112.6322     $6,923.28                          $1,384.66
62361    Implant spine infusion pump                      T      0227          174.4056    $10,720.36                          $2,144.07
62362    Implant spine infusion pump                      T      0227          174.4056    $10,720.36                          $2,144.07
62365    Remove spine infusion device                     T      0221           33.1520     $2,037.79         $463.62            $407.56
62367    Analyze spine infusion pump                      S      0691            2.8942       $177.90          $60.61             $35.58
62368    Analyze spine infusion pump                      S      0691            2.8942       $177.90          $60.61             $35.58
63001    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                            $542.75
63003    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                            $542.75
63005    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                            $542.75
63011    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                            $542.75
63012    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                            $542.75
63015    Removal of spinal lamina                         T      0208           44.1489        2713.74                             542.75
63016    Removal of spinal lamina                         T      0208           44.1489        2713.74                             542.75
63017    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                            $542.75
63020    Neck spine disk surgery                          T      0208           44.1489     $2,713.74                            $542.75
63030    Low back disk surgery                            T      0208           44.1489     $2,713.74                            $542.75
63035    Spinal disk surgery add-on                       T      0208           44.1489     $2,713.74                            $542.75
63040    Laminotomy, single cervical                      T      0208           44.1489     $2,713.74                            $542.75
63042    Laminotomy, single lumbar                        T      0208           44.1489     $2,713.74                            $542.75
63043    Laminotomy, add'l cervical                       C
63044    Laminotomy, add'l lumbar                         C
63045    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                           $542.75
63046    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                           $542.75
63047    Removal of spinal lamina                         T      0208           44.1489     $2,713.74                           $542.75
63048    Remove spinal lamina add-on                      T      0208           44.1489     $2,713.74                           $542.75
63050    Cervical laminoplasty                            C
63051    C-laminoplasty w/graft/plate                     C
63055    Decompress spinal cord                           T      0208     44.1489           $2,713.74                           $542.75
63056    Decompress spinal cord                           T      0208     44.1489
                                                                   Milliman                 $2,713.74                           $542.75
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
63057    Decompress spine cord add-on                     T      0208           44.1489     $2,713.74                   $542.75
63064    Decompress spinal cord                           T      0208           44.1489     $2,713.74                   $542.75
63066    Decompress spine cord add-on                     T      0208           44.1489     $2,713.74                   $542.75
63075    Neck spine disk surgery                          T      0208           44.1489     $2,713.74                   $542.75
63076    Neck spine disk surgery                          C
63077    Spine disk surgery, thorax                       C
63078    Spine disk surgery, thorax                       C
63081    Removal of vertebral body                        C
63082    Remove vertebral body add-on                     C
63085    Removal of vertebral body                        C
63086    Remove vertebral body add-on                     C
63087    Removal of vertebral body                        C
63088    Remove vertebral body add-on                     C
63090    Removal of vertebral body                        C
63091    Remove vertebral body add-on                     C
63101    Removal of vertebral body                        C
63102    Removal of vertebral body                        C
63103    Remove vertebral body add-on                     C
63170    Incise spinal cord tract(s)                      C
63172    Drainage of spinal cyst                          C
63173    Drainage of spinal cyst                          C
63180    Revise spinal cord ligaments                     C
63182    Revise spinal cord ligaments                     C
63185    Incise spinal column/nerves                      C
63190    Incise spinal column/nerves                      C
63191    Incise spinal column/nerves                      C
63194    Incise spinal column & cord                      C
63195    Incise spinal column & cord                      C
63196    Incise spinal column & cord                      C
63197    Incise spinal column & cord                      C
63198    Incise spinal column & cord                      C
63199    Incise spinal column & cord                      C
63200    Release of spinal cord                           C
63250    Revise spinal cord vessels                       C
63251    Revise spinal cord vessels                       C
63252    Revise spinal cord vessels                       C
63265    Excise intraspinal lesion                        C
63266    Excise intraspinal lesion                        C
63267    Excise intraspinal lesion                        C
63268    Excise intraspinal lesion                        C
63270    Excise intraspinal lesion                        C
63271    Excise intraspinal lesion                        C
63272    Excise intraspinal lesion                        C
63273    Excise intraspinal lesion                        C
63275    Biopsy/excise spinal tumor                       C
63276    Biopsy/excise spinal tumor                       C
63277    Biopsy/excise spinal tumor                       C
63278    Biopsy/excise spinal tumor                       C
63280    Biopsy/excise spinal tumor                       C
63281    Biopsy/excise spinal tumor                       C
63282    Biopsy/excise spinal tumor                       C
63283    Biopsy/excise spinal tumor                       C
63285    Biopsy/excise spinal tumor                       C        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment           Copayment
63286    Biopsy/excise spinal tumor                       C
63287    Biopsy/excise spinal tumor                       C
63290    Biopsy/excise spinal tumor                       C
63295    Repair of laminectomy defect                     C
63300    Removal of vertebral body                        C
63301    Removal of vertebral body                        C
63302    Removal of vertebral body                        C
63303    Removal of vertebral body                        C
63304    Removal of vertebral body                        C
63305    Removal of vertebral body                        C
63306    Removal of vertebral body                        C
63307    Removal of vertebral body                        C
63308    Remove vertebral body add-on                     C
63600    Remove spinal cord lesion                        T      0220           17.8499     $1,097.20                          $219.44
63610    Stimulation of spinal cord                       T      0220           17.8499     $1,097.20                          $219.44
63615    Remove lesion of spinal cord                     T      0220           17.8499     $1,097.20                          $219.44
63650    Implant neuroelectrodes                          S      0040           56.5705     $3,477.28                          $695.46
63655    Implant neuroelectrodes                          S      0061           84.1967     $5,175.40                        $1,035.08
63660    Revise/remove neuroelectrode                     T      0687           17.8334     $1,096.18        $438.47           $219.24
63685    Insrt/redo spine n generator                     T      0222          181.6249    $11,164.12                        $2,232.82
63688    Revise/remove neuroreceiver                      T      0688           35.5702     $2,186.43        $874.57           $437.29
63700    Repair of spinal herniation                      C
63702    Repair of spinal herniation                      C
63704    Repair of spinal herniation                      C
63706    Repair of spinal herniation                      C
63707    Repair spinal fluid leakage                      C
63709    Repair spinal fluid leakage                      C
63710    Graft repair of spine defect                     C
63740    Install spinal shunt                             C
63741    Install spinal shunt                             T      0228     39.2633           $2,413.44                         $482.69
63744    Revision of spinal shunt                         T      0228     39.2633           $2,413.44                         $482.69
63746    Removal of spinal shunt                          T      0109     10.9918             $675.64                         $135.13
64400    Nblock inj, trigeminal                           T      0204       2.2614            $139.00            $40.13        $27.80
64402    Nblock inj, facial                               T      0204       2.2614            $139.00            $40.13        $27.80
64405    Nblock inj, occipital                            T      0204       2.2614            $139.00            $40.13        $27.80
64408    Nblock inj, vagus                                T      0204       2.2614            $139.00            $40.13        $27.80
64410    Nblock inj, phrenic                              T      0206       5.7253            $351.92            $75.55        $70.38
64412    Nblock inj, spinal accessor                      T      0206       5.7253            $351.92            $75.55        $70.38
64413    Nblock inj, cervical plexus                      T      0204       2.2614            $139.00            $40.13        $27.80
64415    Nblock inj, brachial plexus                      T      0204       2.2614            $139.00            $40.13        $27.80
64416    Nblock cont infuse, b plex                       T      0204       2.2614            $139.00            $40.13        $27.80
64417    Nblock inj, axillary                             T      0204       2.2614            $139.00            $40.13        $27.80
64418    Nblock inj, suprascapular                        T      0204       2.2614            $139.00            $40.13        $27.80
64420    Nblock inj, intercost, sng                       T      0204       2.2614            $139.00            $40.13        $27.80
64421    Nblock inj, intercost, mlt                       T      0206       5.7253            $351.92            $75.55        $70.38
64425    Nblock inj, ilio-ing/hypogi                      T      0204       2.2614            $139.00            $40.13        $27.80
64430    Nblock inj, pudendal                             T      0204       2.2614            $139.00            $40.13        $27.80
64435    Nblock inj, paracervical                         T      0204       2.2614            $139.00            $40.13        $27.80
64445    Nblock inj, sciatic, sng                         T      0204       2.2614            $139.00            $40.13        $27.80
64446    Nblk inj, sciatic, cont inf                      T      0206       5.7253            $351.92            $75.55        $70.38
64447    Nblock inj fem, single                           T      0204       2.2614            $139.00            $40.13        $27.80
64448    Nblock inj fem, cont inf                         T      0204       2.2614            $139.00            $40.13        $27.80
64449    Nblock inj, lumbar plexus                        T        Milliman 2.2614
                                                                 0204                         $139.00            $40.13        $27.80
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
64450    Nblock, other peripheral                         T      0204            2.2614       $139.00      $40.13     $27.80
64470    Inj paravertebral c/t                            T      0207            6.3603       $390.95      $86.92     $78.19
64472    Inj paravertebral c/t add-on                     T      0206            5.7253       $351.92      $75.55     $70.38
64475    Inj paravertebral l/s                            T      0207            6.3603       $390.95      $86.92     $78.19
64476    Inj paravertebral l/s add-on                     T      0206            5.7253       $351.92      $75.55     $70.38
64479    Inj foramen epidural c/t                         T      0207            6.3603       $390.95      $86.92     $78.19
64480    Inj foramen epidural add-on                      T      0207            6.3603       $390.95      $86.92     $78.19
64483    Inj foramen epidural l/s                         T      0207            6.3603         390.95       86.92      78.19
64484    Inj foramen epidural add-on                      T      0207            6.3603       $390.95      $86.92     $78.19
64505    Nblock, spenopalatine gangl                      T      0204            2.2614       $139.00      $40.13     $27.80
64508    Nblock, carotid sinus s/p                        T      0204            2.2614       $139.00      $40.13     $27.80
64510    Nblock, stellate ganglion                        T      0207            6.3603       $390.95      $86.92     $78.19
64517    Nblock inj, hypogas plxs                         T      0204            2.2614       $139.00        40.13    $27.80
64520    Nblock, lumbar/thoracic                          T      0207            6.3603       $390.95      $86.92     $78.19
64530    Nblock inj, celiac pelus                         T      0207            6.3603       $390.95      $86.92     $78.19
64550    Apply neurostimulator                            A
64553    Implant neuroelectrodes                          S      0225     221.1512         $13,593.72                      $2,718.74
64555    Implant neuroelectrodes                          S      0040      56.5705          $3,477.28                        $695.46
64560    Implant neuroelectrodes                          S      0040      56.5705          $3,477.28                        $695.46
64561    Implant neuroelectrodes                          S      0040      56.5705          $3,477.28                        $695.46
64565    Implant neuroelectrodes                          S      0040      56.5705          $3,477.28                        $695.46
64573    Implant neuroelectrodes                          S      0225     221.1512         $13,593.72                      $2,718.74
64575    Implant neuroelectrodes                          S      0061      84.1967          $5,175.40                      $1,035.08
64577    Implant neuroelectrodes                          S      0061      84.1967          $5,175.40                      $1,035.08
64580    Implant neuroelectrodes                          S      0061      84.1967          $5,175.40                      $1,035.08
64581    Implant neuroelectrodes                          S      0061      84.1967          $5,175.40                      $1,035.08
64585    Revise/remove neuroelectrode                     T      0687      17.8334          $1,096.18        $438.47         $219.24
64590    Insrt/redo pn/gastr stimul                       T      0222     181.6249         $11,164.12                      $2,232.82
64595    Revise/rmv pn/gastr stimul                       T      0688      35.5702          $2,186.43          874.57        $437.29
64600    Injection treatment of nerve                     T      0203      12.1702            $748.08        $240.33         $149.62
64605    Injection treatment of nerve                     T      0203      12.1702            $748.08        $240.33         $149.62
64610    Injection treatment of nerve                     T      0203      12.1702            $748.08        $240.33         $149.62
64612    Destroy nerve, face muscle                       T      0204       2.2614            $139.00         $40.13          $27.80
64613    Destroy nerve, neck muscle                       T      0204       2.2614            $139.00         $40.13          $27.80
64614    Destroy nerve, extrem musc                       T      0204       2.2614            $139.00           40.13         $27.80
64620    Injection treatment of nerve                     T      0203      12.1702            $748.08        $240.33         $149.62
64622    Destr paravertebrl nerve l/s                     T      0203      12.1702            $748.08        $240.33         $149.62
64623    Destr paravertebral n add-on                     T      0207       6.3603            $390.95         $86.92          $78.19
64626    Destr paravertebrl nerve c/t                     T      0203      12.1702            $748.08        $240.33         $149.62
64627    Destr paravertebral n add-on                     T      0207       6.3603            $390.95         $86.92          $78.19
64630    Injection treatment of nerve                     T      0206       5.7253            $351.92         $75.55          $70.38
64640    Injection treatment of nerve                     T      0206       5.7253            $351.92         $75.55          $70.38
64650    Chemodenerv eccrine glands                       T      0204       2.2614            $139.00         $40.13          $27.80
64653    Chemodenerv eccrine glands                       T      0204       2.2614            $139.00         $40.13          $27.80
64680    Injection treatment of nerve                     T      0207       6.3603            $390.95         $86.92          $78.19
64681    Injection treatment of nerve                     T      0203      12.1702            $748.08        $240.33         $149.62
64702    Revise finger/toe nerve                          T      0220      17.8499          $1,097.20                        $219.44
64704    Revise hand/foot nerve                           T      0220      17.8499          $1,097.20                        $219.44
64708    Revise arm/leg nerve                             T      0220      17.8499          $1,097.20                        $219.44
64712    Revision of sciatic nerve                        T      0220      17.8499          $1,097.20                        $219.44
64713    Revision of arm nerve(s)                         T      0220      17.8499          $1,097.20                        $219.44
64714    Revise low back nerve(s)                         T      0220      17.8499          $1,097.20                        $219.44
64716    Revision of cranial nerve                        T      0220
                                                                   Milliman17.8499          $1,097.20                        $219.44
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468         2007 CF
                                                                                                        National        Minimum
HCPCS/                                                                         Relative                Unadjusted       Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment        Copayment
64718    Revise ulnar nerve at elbow                      T      0220           17.8499     $1,097.20                      $219.44
64719    Revise ulnar nerve at wrist                      T      0220           17.8499     $1,097.20                      $219.44
64721    Carpal tunnel surgery                            T      0220           17.8499     $1,097.20                      $219.44
64722    Relieve pressure on nerve(s)                     T      0220           17.8499     $1,097.20                      $219.44
64726    Release foot/toe nerve                           T      0220           17.8499     $1,097.20                      $219.44
64727    Internal nerve revision                          T      0220           17.8499     $1,097.20                      $219.44
64732    Incision of brow nerve                           T      0220           17.8499     $1,097.20                      $219.44
64734    Incision of cheek nerve                          T      0220           17.8499     $1,097.20                      $219.44
64736    Incision of chin nerve                           T      0220           17.8499     $1,097.20                      $219.44
64738    Incision of jaw nerve                            T      0220           17.8499     $1,097.20                      $219.44
64740    Incision of tongue nerve                         T      0220           17.8499     $1,097.20                      $219.44
64742    Incision of facial nerve                         T      0220           17.8499     $1,097.20                      $219.44
64744    Incise nerve, back of head                       T      0220           17.8499     $1,097.20                      $219.44
64746    Incise diaphragm nerve                           T      0220           17.8499     $1,097.20                      $219.44
64752    Incision of vagus nerve                          C
64755    Incision of stomach nerves                       C
64760    Incision of vagus nerve                          C
64761    Incision of pelvis nerve                         T      0220           17.8499     $1,097.20                      $219.44
64763    Incise hip/thigh nerve                           T      0220           17.8499     $1,097.20                      $219.44
64766    Incise hip/thigh nerve                           T      0221           33.1520     $2,037.79        $463.62       $407.56
64771    Sever cranial nerve                              T      0220           17.8499     $1,097.20                      $219.44
64772    Incision of spinal nerve                         T      0220           17.8499     $1,097.20                      $219.44
64774    Remove skin nerve lesion                         T      0220           17.8499     $1,097.20                      $219.44
64776    Remove digit nerve lesion                        T      0220           17.8499     $1,097.20                      $219.44
64778    Digit nerve surgery add-on                       T      0220           17.8499     $1,097.20                      $219.44
64782    Remove limb nerve lesion                         T      0220           17.8499     $1,097.20                      $219.44
64783    Limb nerve surgery add-on                        T      0220           17.8499     $1,097.20                      $219.44
64784    Remove nerve lesion                              T      0220           17.8499     $1,097.20                      $219.44
64786    Remove sciatic nerve lesion                      T      0221           33.1520     $2,037.79        $463.62       $407.56
64787    Implant nerve end                                T      0220           17.8499     $1,097.20                      $219.44
64788    Remove skin nerve lesion                         T      0220           17.8499     $1,097.20                      $219.44
64790    Removal of nerve lesion                          T      0220           17.8499     $1,097.20                      $219.44
64792    Removal of nerve lesion                          T      0221           33.1520     $2,037.79        $463.62       $407.56
64795    Biopsy of nerve                                  T      0220           17.8499     $1,097.20                      $219.44
64802    Remove sympathetic nerves                        T      0220           17.8499     $1,097.20                      $219.44
64804    Remove sympathetic nerves                CH      T      0220           17.8499     $1,097.20                      $219.44
64809    Remove sympathetic nerves                        C
64818    Remove sympathetic nerves                        C
64820    Remove sympathetic nerves                        T      0220     17.8499           $1,097.20                      $219.44
64821    Remove sympathetic nerves                        T      0054     25.8758           $1,590.53                      $318.11
64822    Remove sympathetic nerves                        T      0054     25.8758           $1,590.53                      $318.11
64823    Remove sympathetic nerves                        T      0054     25.8758           $1,590.53                      $318.11
64831    Repair of digit nerve                            T      0221     33.1520           $2,037.79        $463.62       $407.56
64832    Repair nerve add-on                              T      0221     33.1520           $2,037.79        $463.62       $407.56
64834    Repair of hand or foot nerve                     T      0221     33.1520           $2,037.79        $463.62       $407.56
64835    Repair of hand or foot nerve                     T      0221     33.1520           $2,037.79        $463.62       $407.56
64836    Repair of hand or foot nerve                     T      0221     33.1520           $2,037.79        $463.62       $407.56
64837    Repair nerve add-on                              T      0221     33.1520           $2,037.79        $463.62       $407.56
64840    Repair of leg nerve                              T      0221     33.1520           $2,037.79        $463.62       $407.56
64856    Repair/transpose nerve                           T      0221     33.1520           $2,037.79        $463.62       $407.56
64857    Repair arm/leg nerve                             T      0221     33.1520           $2,037.79        $463.62       $407.56
64858    Repair sciatic nerve                             T      0221     33.1520           $2,037.79        $463.62       $407.56
64859    Nerve surgery                                    T      0221     33.1520
                                                                   Milliman                 $2,037.79        $463.62       $407.56
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 84 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468         2007 CF
                                                                                                        National        Minimum
HCPCS/                                                                         Relative                Unadjusted       Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment        Copayment
64861    Repair of arm nerves                             T      0221           33.1520     $2,037.79     $463.62          $407.56
64862    Repair of low back nerves                        T      0221           33.1520     $2,037.79     $463.62          $407.56
64864    Repair of facial nerve                           T      0221           33.1520     $2,037.79     $463.62          $407.56
64865    Repair of facial nerve                           T      0221           33.1520     $2,037.79     $463.62          $407.56
64866    Fusion of facial/other nerve                     C
64868    Fusion of facial/other nerve                     C
64870    Fusion of facial/other nerve                     T      0221           33.1520     $2,037.79        $463.62       $407.56
64872    Subsequent repair of nerve                       T      0221           33.1520     $2,037.79        $463.62       $407.56
64874    Repair & revise nerve add-on                     T      0221           33.1520     $2,037.79        $463.62       $407.56
64876    Repair nerve/shorten bone                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64885    Nerve graft, head or neck                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64886    Nerve graft, head or neck                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64890    Nerve graft, hand or foot                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64891    Nerve graft, hand or foot                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64892    Nerve graft, arm or leg                          T      0221           33.1520     $2,037.79        $463.62       $407.56
64893    Nerve graft, arm or leg                          T      0221           33.1520     $2,037.79        $463.62       $407.56
64895    Nerve graft, hand or foot                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64896    Nerve graft, hand or foot                        T      0221           33.1520     $2,037.79        $463.62       $407.56
64897    Nerve graft, arm or leg                          T      0221           33.1520     $2,037.79        $463.62       $407.56
64898    Nerve graft, arm or leg                          T      0221           33.1520     $2,037.79        $463.62       $407.56
64901    Nerve graft add-on                               T      0221           33.1520     $2,037.79        $463.62       $407.56
64902    Nerve graft add-on                               T      0221           33.1520     $2,037.79        $463.62       $407.56
64905    Nerve pedicle transfer                           T      0221           33.1520     $2,037.79        $463.62       $407.56
64907    Nerve pedicle transfer                           T      0221           33.1520     $2,037.79        $463.62       $407.56
64910    Nerve repair w/allograft                 NI      T      0220           17.8499     $1,097.20                      $219.44
64911    Neurorraphy w/vein autograft             NI      T      0220           17.8499     $1,097.20                      $219.44
64999    Nervous system surgery                           T      0204            2.2614       $139.00         $40.13        $27.80
65091    Revise eye                                       T      0242           35.2292     $2,165.47        $597.36       $433.09
65093    Revise eye with implant                  CH      T      0242           35.2292     $2,165.47        $597.36       $433.09
65101    Removal of eye                                   T      0242           35.2292     $2,165.47        $597.36       $433.09
65103    Remove eye/insert implant                        T      0242           35.2292     $2,165.47        $597.36       $433.09
65105    Remove eye/attach implant                        T      0242           35.2292     $2,165.47        $597.36       $433.09
65110    Removal of eye                                   T      0242           35.2292     $2,165.47        $597.36       $433.09
65112    Remove eye/revise socket                         T      0242           35.2292     $2,165.47        $597.36       $433.09
65114    Remove eye/revise socket                         T      0242           35.2292     $2,165.47        $597.36       $433.09
65125    Revise ocular implant                            T      0240           17.1243     $1,052.60        $309.52       $210.52
65130    Insert ocular implant                            T      0241           25.2550     $1,552.37        $384.47       $310.47
65135    Insert ocular implant                            T      0241           25.2550     $1,552.37        $384.47       $310.47
65140    Attach ocular implant                            T      0242           35.2292     $2,165.47        $597.36       $433.09
65150    Revise ocular implant                            T      0241           25.2550     $1,552.37        $384.47       $310.47
65155    Reinsert ocular implant                          T      0242           35.2292     $2,165.47        $597.36       $433.09
65175    Removal of ocular implant                        T      0240           17.1243     $1,052.60        $309.52       $210.52
65205    Remove foreign body from eye                     S      0698            1.1607        $71.35                       $14.27
65210    Remove foreign body from eye                     S      0698            1.1607        $71.35                       $14.27
65220    Remove foreign body from eye                     S      0698            1.1607        $71.35                       $14.27
65222    Remove foreign body from eye                     S      0698            1.1607        $71.35                       $14.27
65235    Remove foreign body from eye                     T      0233           15.2259       $935.91        $266.33       $187.18
65260    Remove foreign body from eye                     T      0236           16.5239     $1,015.69                      $203.14
65265    Remove foreign body from eye                     T      0237           27.6020     $1,696.64                      $339.33
65270    Repair of eye wound                              T      0240           17.1243     $1,052.60        $309.52       $210.52
65272    Repair of eye wound                              T      0234           22.9970     $1,413.58        $511.31       $282.72
65273    Repair of eye wound                              C
65275    Repair of eye wound                              T      0234     22.9970
                                                                   Milliman                 $1,413.58        $511.31       $282.72
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
65280    Repair of eye wound                              T      0236           16.5239     $1,015.69                $203.14
65285    Repair of eye wound                              T      0672           37.4290     $2,300.69                $460.14
65286    Repair of eye wound                              T      0232            6.0673       $372.94      $93.43     $74.59
65290    Repair of eye socket wound                       T      0243           21.2801     $1,308.05     $430.35    $261.61
65400    Removal of eye lesion                            T      0233           15.2259         935.91      266.33     187.18
65410    Biopsy of cornea                                 T      0233           15.2259       $935.91     $266.33    $187.18
65420    Removal of eye lesion                            T      0233           15.2259       $935.91     $266.33    $187.18
65426    Removal of eye lesion                            T      0234           22.9970     $1,413.58     $511.31    $282.72
65430    Corneal smear                                    S      0698            1.1607        $71.35                 $14.27
65435    Curette/treat cornea                             T      0239            7.2819          447.6                  89.52
65436    Curette/treat cornea                             T      0233           15.2259       $935.91     $266.33    $187.18
65450    Treatment of corneal lesion                      S      0231            2.1451       $131.86                 $26.37
65600    Revision of cornea                               T      0240           17.1243     $1,052.60     $309.52    $210.52
65710    Corneal transplant                               T      0244           38.2707     $2,352.42     $803.26    $470.48
65730    Corneal transplant                               T      0244           38.2707     $2,352.42     $803.26    $470.48
65750    Corneal transplant                               T      0244           38.2707     $2,352.42     $803.26    $470.48
65755    Corneal transplant                               T      0244           38.2707     $2,352.42     $803.26    $470.48
65760    Revision of cornea                               E
65765    Revision of cornea                               E
65767    Corneal tissue transplant                        E
65770    Revise cornea with implant               CH      T      0293           51.9894     $3,195.68             1128.29       $639.14
65771    Radial keratotomy                                E
65772    Correction of astigmatism                        T      0233     15.2259             $935.91         $266.33           $187.18
65775    Correction of astigmatism                        T      0233     15.2259             $935.91         $266.33           $187.18
65780    Ocular reconst, transplant                       T      0244     38.2707           $2,352.42           803.26          $470.48
65781    Ocular reconst, transplant                       T      0244     38.2707           $2,352.42           803.26          $470.48
65782    Ocular reconst, transplant                       T      0244     38.2707           $2,352.42           803.26          $470.48
65800    Drainage of eye                                  T      0233     15.2259             $935.91           266.33          $187.18
65805    Drainage of eye                                  T      0233     15.2259             $935.91           266.33          $187.18
65810    Drainage of eye                                  T      0234     22.9970           $1,413.58         $511.31           $282.72
65815    Drainage of eye                                  T      0234     22.9970           $1,413.58         $511.31           $282.72
65820    Relieve inner eye pressure                       T      0232       6.0673            $372.94            93.43           $74.59
65850    Incision of eye                                  T      0234     22.9970           $1,413.58         $511.31           $282.72
65855    Laser surgery of eye                             T      0247       5.0839            $312.50         $104.31            $62.50
65860    Incise inner eye adhesions                       T      0247       5.0839            $312.50         $104.31            $62.50
65865    Incise inner eye adhesions                       T      0233     15.2259             $935.91         $266.33           $187.18
65870    Incise inner eye adhesions                       T      0234     22.9970           $1,413.58         $511.31           $282.72
65875    Incise inner eye adhesions                       T      0234     22.9970           $1,413.58           511.31          $282.72
65880    Incise inner eye adhesions                       T      0233     15.2259             $935.91           266.33          $187.18
65900    Remove eye lesion                                T      0233     15.2259             $935.91         $266.33           $187.18
65920    Remove implant of eye                            T      0234     22.9970           $1,413.58           511.31          $282.72
65930    Remove blood clot from eye                       T      0234     22.9970           $1,413.58           511.31          $282.72
66020    Injection treatment of eye                       T      0233     15.2259             $935.91           266.33          $187.18
66030    Injection treatment of eye                       T      0232       6.0673              372.94           93.43             74.59
66130    Remove eye lesion                                T      0234     22.9970           $1,413.58         $511.31           $282.72
66150    Glaucoma surgery                                 T      0234     22.9970           $1,413.58           511.31          $282.72
66155    Glaucoma surgery                                 T      0234     22.9970           $1,413.58           511.31          $282.72
66160    Glaucoma surgery                                 T      0234     22.9970              1413.58          511.31            282.72
66165    Glaucoma surgery                                 T      0234     22.9970           $1,413.58           511.31          $282.72
66170    Glaucoma surgery                                 T      0234     22.9970           $1,413.58           511.31          $282.72
66172    Incision of eye                          CH      T      0234     22.9970           $1,413.58           511.31          $282.72
66180    Implant eye shunt                                T      0673     37.8967           $2,329.43           649.56          $465.89
66185    Revise eye shunt                                 T      0673     37.8967
                                                                   Milliman                 $2,329.43           649.56          $465.89
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                          Page 86 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468           2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
66220    Repair eye lesion                                T      0672           37.4290     $2,300.69                $460.14
66225    Repair/graft eye lesion                          T      0673           37.8967     $2,329.43     $649.56    $465.89
66250    Follow-up surgery of eye                         T      0233           15.2259       $935.91       266.33   $187.18
66500    Incision of iris                                 T      0232            6.0673       $372.94        93.43    $74.59
66505    Incision of iris                                 T      0232            6.0673       $372.94        93.43    $74.59
66600    Remove iris and lesion                           T      0234           22.9970     $1,413.58       511.31   $282.72
66605    Removal of iris                                  T      0234           22.9970     $1,413.58       511.31   $282.72
66625    Removal of iris                                  T      0232            6.0673       $372.94        93.43    $74.59
66630    Removal of iris                                  T      0234           22.9970     $1,413.58       511.31   $282.72
66635    Removal of iris                                  T      0234           22.9970     $1,413.58       511.31   $282.72
66680    Repair iris & ciliary body                       T      0234           22.9970     $1,413.58       511.31   $282.72
66682    Repair iris & ciliary body                       T      0234           22.9970     $1,413.58       511.31   $282.72
66700    Destruction, ciliary body                        T      0233           15.2259       $935.91       266.33   $187.18
66710    Ciliary transsleral therapy                      T      0233           15.2259       $935.91       266.33   $187.18
66711    Ciliary endoscopic ablation                      T      0233           15.2259       $935.91     $266.33    $187.18
66720    Destruction, ciliary body                        T      0233           15.2259       $935.91       266.33   $187.18
66740    Destruction, ciliary body                        T      0234           22.9970     $1,413.58       511.31   $282.72
66761    Revision of iris                                 T      0247            5.0839       $312.50       104.31    $62.50
66762    Revision of iris                                 T      0247            5.0839       $312.50       104.31    $62.50
66770    Removal of inner eye lesion                      T      0247            5.0839       $312.50       104.31    $62.50
66820    Incision, secondary cataract                     T      0232            6.0673       $372.94        93.43    $74.59
66821    After cataract laser surgery                     T      0247            5.0839       $312.50       104.31    $62.50
66825    Reposition intraocular lens                      T      0234           22.9970     $1,413.58       511.31   $282.72
66830    Removal of lens lesion                           T      0232            6.0673         372.94       93.43      74.59
66840    Removal of lens material                         T      0245           14.8702       $914.04       217.05   $182.81
66850    Removal of lens material                         T      0249           29.2281     $1,796.59       524.67   $359.32
66852    Removal of lens material                         T      0249           29.2281     $1,796.59       524.67   $359.32
66920    Extraction of lens                               T      0249           29.2281     $1,796.59       524.67   $359.32
66930    Extraction of lens                               T      0249           29.2281     $1,796.59       524.67   $359.32
66940    Extraction of lens                               T      0245           14.8702       $914.04       217.05   $182.81
66982    Cataract surgery, complex                        T      0246           23.6313     $1,452.57       495.96   $290.51
66983    Cataract surg w/iol, 1 stage                     T      0246           23.6313     $1,452.57       495.96   $290.51
66984    Cataract surg w/iol, 1 stage                     T      0246           23.6313     $1,452.57       495.96   $290.51
66985    Insert lens prosthesis                           T      0246           23.6313     $1,452.57     $495.96    $290.51
66986    Exchange lens prosthesis                         T      0246           23.6313     $1,452.57       495.96   $290.51
66990    Ophthalmic endoscope add-on                      N
66999    Eye surgery procedure                            T      0232       6.0673            $372.94             93.43        $74.59
67005    Partial removal of eye fluid                     T      0237     27.6020           $1,696.64                         $339.33
67010    Partial removal of eye fluid                     T      0237     27.6020           $1,696.64                         $339.33
67015    Release of eye fluid                             T      0237     27.6020           $1,696.64                         $339.33
67025    Replace eye fluid                                T      0237     27.6020           $1,696.64                         $339.33
67027    Implant eye drug system                          T      0672     37.4290           $2,300.69                         $460.14
67028    Injection eye drug                               T      0235       3.9333            $241.77             58.93        $48.35
67030    Incise inner eye strands                         T      0236     16.5239           $1,015.69                         $203.14
67031    Laser surgery, eye strands                       T      0247       5.0839            $312.50         $104.31          $62.50
67036    Removal of inner eye fluid                       T      0672     37.4290              2300.69                          460.14
67038    Strip retinal membrane                           T      0672     37.4290           $2,300.69                         $460.14
67039    Laser treatment of retina                        T      0672     37.4290           $2,300.69                         $460.14
67040    Laser treatment of retina                        T      0672     37.4290              2300.69                          460.14
67101    Repair detached retina                           T      0236     16.5239           $1,015.69                         $203.14
67105    Repair detached retina                           T      0248       5.0841              312.51            95.08           62.5
67107    Repair detached retina                           T      0672     37.4290           $2,300.69                         $460.14
67108    Repair detached retina                           T      0672     37.4290
                                                                   Milliman                 $2,300.69                         $460.14
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                        Page 87 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468         2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
67110    Repair detached retina                           T      0236           16.5239     $1,015.69                $203.14
67112    Rerepair detached retina                         T      0672           37.4290     $2,300.69                $460.14
67115    Release encircling material                      T      0236           16.5239     $1,015.69                $203.14
67120    Remove eye implant material                      T      0236           16.5239     $1,015.69                $203.14
67121    Remove eye implant material                      T      0237           27.6020     $1,696.64                $339.33
67141    Treatment of retina                              T      0235            3.9333       $241.77        58.93    $48.35
67145    Treatment of retina                              T      0248            5.0841       $312.51      $95.08     $62.50
67208    Treatment of retinal lesion                      T      0236           16.5239     $1,015.69                $203.14
67210    Treatment of retinal lesion                      T      0248            5.0841       $312.51      $95.08     $62.50
67218    Treatment of retinal lesion                      T      0236           16.5239     $1,015.69                $203.14
67220    Treatment of choroid lesion                      T      0235            3.9333       $241.77      $58.93     $48.35
67221    Ocular photodynamic ther                         T      0235            3.9333       $241.77      $58.93     $48.35
67225    Eye photodynamic ther add-on                     T      0235            3.9333       $241.77      $58.93     $48.35
67227    Treatment of retinal lesion              CH      T      0237           27.6020     $1,696.64                $339.33
67228    Treatment of retinal lesion                      T      0248            5.0841       $312.51      $95.08     $62.50
67250    Reinforce eye wall                               T      0240           17.1243     $1,052.60     $309.52    $210.52
67255    Reinforce/graft eye wall                         T      0237           27.6020     $1,696.64                $339.33
67299    Eye surgery procedure                            T      0235            3.9333       $241.77      $58.93     $48.35
67311    Revise eye muscle                                T      0243           21.2801     $1,308.05     $430.35    $261.61
67312    Revise two eye muscles                           T      0243           21.2801     $1,308.05     $430.35    $261.61
67314    Revise eye muscle                                T      0243           21.2801     $1,308.05     $430.35    $261.61
67316    Revise two eye muscles                           T      0243           21.2801     $1,308.05     $430.35    $261.61
67318    Revise eye muscle(s)                             T      0243           21.2801     $1,308.05     $430.35    $261.61
67320    Revise eye muscle(s) add-on                      T      0243           21.2801     $1,308.05     $430.35    $261.61
67331    Eye surgery follow-up add-on                     T      0243           21.2801     $1,308.05     $430.35    $261.61
67332    Rerevise eye muscles add-on                      T      0243           21.2801     $1,308.05     $430.35    $261.61
67334    Revise eye muscle w/suture                       T      0243           21.2801     $1,308.05     $430.35    $261.61
67335    Eye suture during surgery                        T      0243           21.2801     $1,308.05     $430.35    $261.61
67340    Revise eye muscle add-on                         T      0243           21.2801     $1,308.05     $430.35    $261.61
67343    Release eye tissue                               T      0243           21.2801     $1,308.05     $430.35    $261.61
67345    Destroy nerve of eye muscle                      T      0238            2.8954       $177.97                 $35.59
67346    Biopsy, eye muscle                       NI      T      0699           14.3845       $884.19                $176.84
67350    Biopsy eye muscle                        CH      D
67399    Eye muscle surgery procedure                     T      0243     21.2801           $1,308.05        $430.35       $261.61
67400    Explore/biopsy eye socket                        T      0241     25.2550           $1,552.37        $384.47       $310.47
67405    Explore/drain eye socket                         T      0241     25.2550           $1,552.37        $384.47       $310.47
67412    Explore/treat eye socket                         T      0241     25.2550           $1,552.37        $384.47       $310.47
67413    Explore/treat eye socket                         T      0241     25.2550           $1,552.37        $384.47       $310.47
67414    Explr/decompress eye socket                      T      0242     35.2292           $2,165.47        $597.36       $433.09
67415    Aspiration, orbital contents                     T      0240     17.1243           $1,052.60        $309.52       $210.52
67420    Explore/treat eye socket                         T      0242     35.2292           $2,165.47        $597.36       $433.09
67430    Explore/treat eye socket                         T      0242     35.2292           $2,165.47        $597.36       $433.09
67440    Explore/drain eye socket                         T      0242     35.2292           $2,165.47        $597.36       $433.09
67445    Explr/decompress eye socket                      T      0242     35.2292           $2,165.47        $597.36       $433.09
67450    Explore/biopsy eye socket                        T      0242     35.2292           $2,165.47        $597.36       $433.09
67500    Inject/treat eye socket                          S      0231       2.1451            $131.86                       $26.37
67505    Inject/treat eye socket                          T      0238       2.8954            $177.97                       $35.59
67515    Inject/treat eye socket                          T      0238       2.8954            $177.97                       $35.59
67550    Insert eye socket implant                        T      0242     35.2292           $2,165.47        $597.36       $433.09
67560    Revise eye socket implant                        T      0241     25.2550           $1,552.37        $384.47       $310.47
67570    Decompress optic nerve                           T      0242     35.2292           $2,165.47        $597.36       $433.09
67599    Orbit surgery procedure                          T      0238       2.8954            $177.97                       $35.59
67700    Drainage of eyelid abscess                       T        Milliman 2.8954
                                                                 0238                         $177.97                       $35.59
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 88 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                61.468      2007 CF
                                                                                                   National   Minimum
HCPCS/                                                                   Relative                 Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC      Weight     Payment Rate Copayment Copayment
67710    Incision of eyelid                               T      0239       7.2819       $447.60                 $89.52
67715    Incision of eyelid fold                          T      0240      17.1243     $1,052.60     $309.52    $210.52
67800    Remove eyelid lesion                             T      0238       2.8954       $177.97                 $35.59
67801    Remove eyelid lesions                            T      0239       7.2819       $447.60                 $89.52
67805    Remove eyelid lesions                            T      0238       2.8954       $177.97                 $35.59
67808    Remove eyelid lesion(s)                          T      0240      17.1243     $1,052.60     $309.52    $210.52
67810    Biopsy of eyelid                                 T      0238       2.8954       $177.97                 $35.59
67820    Revise eyelashes                                 S      0698       1.1607        $71.35                 $14.27
67825    Revise eyelashes                                 T      0238       2.8954       $177.97                 $35.59
67830    Revise eyelashes                                 T      0239       7.2819       $447.60                 $89.52
67835    Revise eyelashes                                 T      0240      17.1243     $1,052.60     $309.52    $210.52
67840    Remove eyelid lesion                             T      0239       7.2819       $447.60                 $89.52
67850    Treat eyelid lesion                              T      0239       7.2819       $447.60                 $89.52
67875    Closure of eyelid by suture                      T      0239       7.2819       $447.60                 $89.52
67880    Revision of eyelid                               T      0233      15.2259       $935.91     $266.33    $187.18
67882    Revision of eyelid                               T      0240      17.1243     $1,052.60     $309.52    $210.52
67900    Repair brow defect                               T      0240      17.1243     $1,052.60     $309.52    $210.52
67901    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67902    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67903    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67904    Repair eyelid defect                             T      0240      17.1243     $1,052.60       309.52   $210.52
67906    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67908    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67909    Revise eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67911    Revise eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67912    Correction eyelid w/implant                      T      0240      17.1243     $1,052.60     $309.52    $210.52
67914    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67915    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67916    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67917    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67921    Repair eyelid defect                             T      0240      17.1243         1052.6      309.52     210.52
67922    Repair eyelid defect                             T      0240      17.1243     $1,052.60       309.52   $210.52
67923    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67924    Repair eyelid defect                             T      0240      17.1243     $1,052.60     $309.52    $210.52
67930    Repair eyelid wound                              T      0240      17.1243     $1,052.60       309.52   $210.52
67935    Repair eyelid wound                              T      0240      17.1243     $1,052.60       309.52   $210.52
67938    Remove eyelid foreign body                       S      0698       1.1607        $71.35                 $14.27
67950    Revision of eyelid                               T      0240      17.1243     $1,052.60     $309.52    $210.52
67961    Revision of eyelid                               T      0240      17.1243     $1,052.60     $309.52    $210.52
67966    Revision of eyelid                               T      0240      17.1243     $1,052.60     $309.52    $210.52
67971    Reconstruction of eyelid                         T      0241      25.2550     $1,552.37     $384.47    $310.47
67973    Reconstruction of eyelid                         T      0241      25.2550     $1,552.37       384.47   $310.47
67974    Reconstruction of eyelid                         T      0241      25.2550     $1,552.37     $384.47    $310.47
67975    Reconstruction of eyelid                         T      0240      17.1243     $1,052.60       309.52   $210.52
67999    Revision of eyelid                               T      0238       2.8954       $177.97                 $35.59
68020    Incise/drain eyelid lining                       T      0240      17.1243     $1,052.60     $309.52    $210.52
68040    Treatment of eyelid lesions                      S      0698       1.1607        $71.35                 $14.27
68100    Biopsy of eyelid lining                          T      0232       6.0673       $372.94      $93.43     $74.59
68110    Remove eyelid lining lesion                      T      0699      14.3845       $884.19                $176.84
68115    Remove eyelid lining lesion                      T      0240      17.1243     $1,052.60     $309.52    $210.52
68130    Remove eyelid lining lesion                      T      0233      15.2259       $935.91     $266.33    $187.18
68135    Remove eyelid lining lesion                      T      0239       7.2819       $447.60                 $89.52
68200    Treat eyelid by injection                        S        Milliman 0.7898
                                                                 0230                     $48.55      $14.97      $9.71
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
68320    Revise/graft eyelid lining                       T      0240           17.1243     $1,052.60     $309.52    $210.52
68325    Revise/graft eyelid lining               CH      T      0241           25.2550     $1,552.37     $384.47    $310.47
68326    Revise/graft eyelid lining                       T      0241           25.2550     $1,552.37     $384.47    $310.47
68328    Revise/graft eyelid lining                       T      0241           25.2550     $1,552.37     $384.47    $310.47
68330    Revise eyelid lining                             T      0234           22.9970     $1,413.58     $511.31    $282.72
68335    Revise/graft eyelid lining                       T      0241           25.2550     $1,552.37     $384.47    $310.47
68340    Separate eyelid adhesions                        T      0240           17.1243     $1,052.60     $309.52    $210.52
68360    Revise eyelid lining                             T      0234           22.9970     $1,413.58     $511.31    $282.72
68362    Revise eyelid lining                             T      0234           22.9970     $1,413.58     $511.31    $282.72
68371    Harvest eye tissue, alograft                     T      0233           15.2259       $935.91     $266.33    $187.18
68399    Eyelid lining surgery                            T      0238            2.8954       $177.97                 $35.59
68400    Incise/drain tear gland                          T      0238            2.8954         177.97                  35.59
68420    Incise/drain tear sac                            T      0240           17.1243     $1,052.60     $309.52    $210.52
68440    Incise tear duct opening                         T      0238            2.8954       $177.97                 $35.59
68500    Removal of tear gland                            T      0241           25.2550     $1,552.37     $384.47    $310.47
68505    Partial removal, tear gland                      T      0241           25.2550     $1,552.37     $384.47    $310.47
68510    Biopsy of tear gland                             T      0240           17.1243     $1,052.60     $309.52    $210.52
68520    Removal of tear sac                              T      0241           25.2550     $1,552.37     $384.47    $310.47
68525    Biopsy of tear sac                               T      0240           17.1243     $1,052.60     $309.52    $210.52
68530    Clearance of tear duct                           T      0240           17.1243     $1,052.60     $309.52    $210.52
68540    Remove tear gland lesion                         T      0241           25.2550     $1,552.37     $384.47    $310.47
68550    Remove tear gland lesion                 CH      T      0241           25.2550        1552.37      384.47     310.47
68700    Repair tear ducts                                T      0241           25.2550     $1,552.37     $384.47    $310.47
68705    Revise tear duct opening                         T      0238            2.8954       $177.97                 $35.59
68720    Create tear sac drain                    CH      T      0241           25.2550     $1,552.37     $384.47    $310.47
68745    Create tear duct drain                           T      0241           25.2550     $1,552.37     $384.47    $310.47
68750    Create tear duct drain                   CH      T      0241           25.2550     $1,552.37     $384.47    $310.47
68760    Close tear duct opening                  CH      S      0231            2.1451       $131.86                 $26.37
68761    Close tear duct opening                          S      0231            2.1451       $131.86                 $26.37
68770    Close tear system fistula                        T      0240           17.1243     $1,052.60     $309.52    $210.52
68801    Dilate tear duct opening                         S      0698            1.1607        $71.35                 $14.27
68810    Probe nasolacrimal duct                          S      0231            2.1451       $131.86                 $26.37
68811    Probe nasolacrimal duct                          T      0240           17.1243     $1,052.60     $309.52    $210.52
68815    Probe nasolacrimal duct                          T      0240           17.1243     $1,052.60     $309.52    $210.52
68840    Explore/irrigate tear ducts              CH      S      0698            1.1607        $71.35                 $14.27
68850    Injection for tear sac x-ray                     N
68899    Tear duct system surgery                 CH      T      0238            2.8954       $177.97                          $35.59
69000    Drain external ear lesion                        T      0006            1.4392        $88.46                          $17.69
69005    Drain external ear lesion                        T      0008           17.5086     $1,076.22                         $215.24
69020    Drain outer ear canal lesion                     T      0006            1.4392        $88.46                          $17.69
69090    Pierce earlobes                                  E
69100    Biopsy of external ear                           T      0019            4.0919       $251.52         $71.87           $50.30
69105    Biopsy of external ear canal                     T      0253           16.4266     $1,009.71        $282.29          $201.94
69110    Remove external ear, partial                     T      0021           15.1024       $928.31        $219.48          $185.66
69120    Removal of external ear                          T      0254           23.3299     $1,434.04        $321.35          $286.81
69140    Remove ear canal lesion(s)                       T      0254           23.3299     $1,434.04        $321.35          $286.81
69145    Remove ear canal lesion(s)                       T      0021           15.1024       $928.31        $219.48          $185.66
69150    Extensive ear canal surgery                      T      0252            7.5511       $464.15        $109.16           $92.83
69155    Extensive ear/neck surgery                       C
69200    Clear outer ear canal                            X      0340       0.6102             $37.51                           $7.50
69205    Clear outer ear canal                            T      0022     20.0656           $1,233.39        $354.45          $246.68
69210    Remove impacted ear wax                          X      0340       0.6102             $37.51                           $7.50
69220    Clean out mastoid cavity                         T        Milliman 0.8432
                                                                 0012                          $51.83            $11.18        $10.37
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
69222    Clean out mastoid cavity                 CH      T      0252            7.5511       $464.15     $109.16     $92.83
69300    Revise external ear                              T      0254           23.3299     $1,434.04     $321.35    $286.81
69310    Rebuild outer ear canal                          T      0256           38.1991     $2,348.02                $469.60
69320    Rebuild outer ear canal                          T      0256           38.1991     $2,348.02                $469.60
69399    Outer ear surgery procedure                      T      0251            2.4520       $150.72                 $30.14
69400    Inflate middle ear canal                         T      0251            2.4520       $150.72                 $30.14
69401    Inflate middle ear canal                         T      0251            2.4520       $150.72                 $30.14
69405    Catheterize middle ear canal                     T      0252            7.5511         464.15      109.16      92.83
69420    Incision of eardrum                              T      0251            2.4520       $150.72                 $30.14
69421    Incision of eardrum                              T      0253           16.4266     $1,009.71     $282.29    $201.94
69424    Remove ventilating tube                          T      0252            7.5511       $464.15     $109.16     $92.83
69433    Create eardrum opening                           T      0252            7.5511       $464.15     $109.16     $92.83
69436    Create eardrum opening                           T      0253           16.4266     $1,009.71       282.29   $201.94
69440    Exploration of middle ear                        T      0254           23.3299     $1,434.04     $321.35    $286.81
69450    Eardrum revision                                 T      0256           38.1991     $2,348.02                $469.60
69501    Mastoidectomy                                    T      0256           38.1991     $2,348.02                $469.60
69502    Mastoidectomy                                    T      0254           23.3299     $1,434.04     $321.35    $286.81
69505    Remove mastoid structures                        T      0256           38.1991     $2,348.02                $469.60
69511    Extensive mastoid surgery                        T      0256           38.1991     $2,348.02                $469.60
69530    Extensive mastoid surgery                        T      0256           38.1991     $2,348.02                $469.60
69535    Remove part of temporal bone                     C
69540    Remove ear lesion                                T      0253           16.4266     $1,009.71        $282.29          $201.94
69550    Remove ear lesion                                T      0256           38.1991     $2,348.02                         $469.60
69552    Remove ear lesion                                T      0256           38.1991     $2,348.02                         $469.60
69554    Remove ear lesion                                C
69601    Mastoid surgery revision                         T      0256     38.1991           $2,348.02                         $469.60
69602    Mastoid surgery revision                         T      0256     38.1991           $2,348.02                         $469.60
69603    Mastoid surgery revision                         T      0256     38.1991           $2,348.02                         $469.60
69604    Mastoid surgery revision                         T      0256     38.1991           $2,348.02                         $469.60
69605    Mastoid surgery revision                         T      0256     38.1991           $2,348.02                         $469.60
69610    Repair of eardrum                                T      0254     23.3299           $1,434.04        $321.35          $286.81
69620    Repair of eardrum                                T      0254     23.3299           $1,434.04        $321.35          $286.81
69631    Repair eardrum structures                        T      0256     38.1991           $2,348.02                         $469.60
69632    Rebuild eardrum structures                       T      0256     38.1991           $2,348.02                         $469.60
69633    Rebuild eardrum structures                       T      0256     38.1991           $2,348.02                         $469.60
69635    Repair eardrum structures                        T      0256     38.1991           $2,348.02                         $469.60
69636    Rebuild eardrum structures                       T      0256     38.1991           $2,348.02                         $469.60
69637    Rebuild eardrum structures                       T      0256     38.1991           $2,348.02                         $469.60
69641    Revise middle ear & mastoid                      T      0256     38.1991           $2,348.02                         $469.60
69642    Revise middle ear & mastoid                      T      0256     38.1991           $2,348.02                         $469.60
69643    Revise middle ear & mastoid                      T      0256     38.1991             2348.02                            469.6
69644    Revise middle ear & mastoid                      T      0256     38.1991           $2,348.02                         $469.60
69645    Revise middle ear & mastoid                      T      0256     38.1991           $2,348.02                         $469.60
69646    Revise middle ear & mastoid                      T      0256     38.1991           $2,348.02                         $469.60
69650    Release middle ear bone                          T      0254     23.3299           $1,434.04            321.35       $286.81
69660    Revise middle ear bone                           T      0256     38.1991           $2,348.02                         $469.60
69661    Revise middle ear bone                           T      0256     38.1991           $2,348.02                         $469.60
69662    Revise middle ear bone                           T      0256     38.1991           $2,348.02                         $469.60
69666    Repair middle ear structures                     T      0256     38.1991           $2,348.02                         $469.60
69667    Repair middle ear structures                     T      0256     38.1991           $2,348.02                         $469.60
69670    Remove mastoid air cells                         T      0256     38.1991           $2,348.02                         $469.60
69676    Remove middle ear nerve                          T      0256     38.1991           $2,348.02                         $469.60
69700    Close mastoid fistula                            T      0256     38.1991
                                                                   Milliman                   2348.02                            469.6
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
69710    Implant/replace hearing aid                      E
69711    Remove/repair hearing aid                        T      0256           38.1991     $2,348.02                          $469.60
69714    Implant temple bone w/stimul                     T      0256           38.1991     $2,348.02                          $469.60
69715    Temple bne implnt w/stimulat                     T      0256           38.1991     $2,348.02                          $469.60
69717    Temple bone implant revision                     T      0256           38.1991     $2,348.02                          $469.60
69718    Revise temple bone implant                       T      0256           38.1991     $2,348.02                          $469.60
69720    Release facial nerve                             T      0256           38.1991     $2,348.02                          $469.60
69725    Release facial nerve                             T      0256           38.1991     $2,348.02                          $469.60
69740    Repair facial nerve                              T      0256           38.1991     $2,348.02                          $469.60
69745    Repair facial nerve                              T      0256           38.1991     $2,348.02                          $469.60
69799    Middle ear surgery procedure                     T      0251            2.4520       $150.72                           $30.14
69801    Incise inner ear                                 T      0256           38.1991     $2,348.02                          $469.60
69802    Incise inner ear                                 T      0256           38.1991     $2,348.02                          $469.60
69805    Explore inner ear                                T      0256           38.1991     $2,348.02                          $469.60
69806    Explore inner ear                                T      0256           38.1991     $2,348.02                          $469.60
69820    Establish inner ear window                       T      0256           38.1991     $2,348.02                          $469.60
69840    Revise inner ear window                          T      0256           38.1991     $2,348.02                          $469.60
69905    Remove inner ear                                 T      0256           38.1991     $2,348.02                          $469.60
69910    Remove inner ear & mastoid                       T      0256           38.1991     $2,348.02                          $469.60
69915    Incise inner ear nerve                           T      0256           38.1991     $2,348.02                          $469.60
69930    Implant cochlear device                          T      0259          414.8455    $25,499.72      $8,698.43         $5,099.94
69949    Inner ear surgery procedure                      T      0251            2.4520       $150.72                           $30.14
69950    Incise inner ear nerve                           C
69955    Release facial nerve                             T      0256           38.1991     $2,348.02                         $469.60
69960    Release inner ear canal                          T      0256           38.1991       2348.02                            469.6
69970    Remove inner ear lesion                          C
69979    Temporal bone surgery                            T      0251            2.4520        150.72                                30.14
69990    Microsurgery add-on                              N
70010    Contrast x-ray of brain                          S      0274       2.5544            $157.01            $62.80         $31.40
70015    Contrast x-ray of brain                          S      0274       2.5544            $157.01            $62.80         $31.40
70030    X-ray eye for foreign body                       X      0260       0.7093             $43.60                            $8.72
70100    X-ray exam of jaw                                X      0260       0.7093             $43.60                            $8.72
70110    X-ray exam of jaw                                X      0260       0.7093             $43.60                            $8.72
70120    X-ray exam of mastoids                           X      0260       0.7093             $43.60                            $8.72
70130    X-ray exam of mastoids                           X      0260       0.7093             $43.60                            $8.72
70134    X-ray exam of middle ear                         X      0261       1.2224             $75.14                           $15.03
70140    X-ray exam of facial bones                       X      0260       0.7093             $43.60                            $8.72
70150    X-ray exam of facial bones                       X      0260       0.7093             $43.60                            $8.72
70160    X-ray exam of nasal bones                        X      0260       0.7093             $43.60                            $8.72
70170    X-ray exam of tear duct                          X      0264       2.9586            $181.86            $70.27         $36.37
70190    X-ray exam of eye sockets                        X      0260       0.7093             $43.60                            $8.72
70200    X-ray exam of eye sockets                        X      0260       0.7093             $43.60                            $8.72
70210    X-ray exam of sinuses                            X      0260       0.7093             $43.60                            $8.72
70220    X-ray exam of sinuses                            X      0260       0.7093             $43.60                            $8.72
70240    X-ray exam, pituitary saddle                     X      0260       0.7093             $43.60                            $8.72
70250    X-ray exam of skull                              X      0260       0.7093             $43.60                            $8.72
70260    X-ray exam of skull                              X      0261       1.2224             $75.14                           $15.03
70300    X-ray exam of teeth                              X      0262       0.6550             $40.26                            $8.05
70310    X-ray exam of teeth                              X      0262       0.6550             $40.26                            $8.05
70320    Full mouth x-ray of teeth                        X      0262       0.6550             $40.26                            $8.05
70328    X-ray exam of jaw joint                          X      0260       0.7093             $43.60                            $8.72
70330    X-ray exam of jaw joints                         X      0260       0.7093             $43.60                            $8.72
70332    X-ray exam of jaw joint                          S        Milliman 3.6915
                                                                 0275                         $226.91            $69.09         $45.38
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                 61.468        2007 CF
                                                                                                   National     Minimum
HCPCS/                                                                   Relative                 Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC      Weight     Payment Rate Copayment     Copayment
70336    Magnetic image, jaw joint                        S      0335       4.5523       $279.82     $111.92        $55.96
70350    X-ray head for orthodontia                       X      0260       0.7093           43.6                      8.72
70355    Panoramic x-ray of jaws                          X      0260       0.7093        $43.60                     $8.72
70360    X-ray exam of neck                               X      0260       0.7093        $43.60                     $8.72
70370    Throat x-ray & fluoroscopy                       X      0272       1.2908        $79.34      $31.64        $15.87
70371    Speech evaluation, complex                       X      0272       1.2908        $79.34      $31.64        $15.87
70373    Contrast x-ray of larynx                         X      0263       1.6956       $104.23      $23.77        $20.85
70380    X-ray exam of salivary gland                     X      0260       0.7093        $43.60                     $8.72
70390    X-ray exam of salivary duct                      X      0263       1.6956       $104.23      $23.77        $20.85
70450    Ct head/brain w/o dye                            S      0332       3.0908       $189.99      $75.24        $38.00
70460    Ct head/brain w/dye                              S      0283       4.0825       $250.94     $100.37        $50.19
70470    Ct head/brain w/o & w/dye                        S      0333       4.8405       $297.54     $119.01        $59.51
70480    Ct orbit/ear/fossa w/o dye                       S      0332       3.0908       $189.99      $75.24        $38.00
70481    Ct orbit/ear/fossa w/dye                         S      0283       4.0825       $250.94     $100.37        $50.19
70482    Ct orbit/ear/fossa w/o&w/dye                     S      0333       4.8405       $297.54     $119.01        $59.51
70486    Ct maxillofacial w/o dye                         S      0332       3.0908       $189.99      $75.24        $38.00
70487    Ct maxillofacial w/dye                           S      0283       4.0825       $250.94     $100.37        $50.19
70488    Ct maxillofacial w/o & w/dye                     S      0333       4.8405       $297.54     $119.01        $59.51
70490    Ct soft tissue neck w/o dye                      S      0332       3.0908       $189.99      $75.24        $38.00
70491    Ct soft tissue neck w/dye                        S      0283       4.0825       $250.94     $100.37        $50.19
70492    Ct sft tsue nck w/o & w/dye                      S      0333       4.8405       $297.54     $119.01        $59.51
70496    Ct angiography, head                             S      0662       4.8552       $298.44     $118.88        $59.69
70498    Ct angiography, neck                             S      0662       4.8552       $298.44     $118.88        $59.69
70540    Mri orbit/face/neck w/o dye                      S      0336       5.6745       $348.80     $139.51        $69.76
70542    Mri orbit/face/neck w/dye                        S      0284       6.1231       $376.37     $148.40        $75.27
70543    Mri orbt/fac/nck w/o & w/dye                     S      0337       8.1155       $498.84     $199.53        $99.77
70544    Mr angiography head w/o dye                      S      0336       5.6745       $348.80     $139.51        $69.76
70545    Mr angiography head w/dye                        S      0284       6.1231       $376.37     $148.40        $75.27
70546    Mr angiograph head w/o&w/dye                     S      0337       8.1155       $498.84     $199.53        $99.77
70547    Mr angiography neck w/o dye                      S      0336       5.6745       $348.80     $139.51        $69.76
70548    Mr angiography neck w/dye                        S      0284       6.1231       $376.37     $148.40        $75.27
70549    Mr angiograph neck w/o&w/dye                     S      0337       8.1155       $498.84     $199.53        $99.77
70551    Mri brain w/o dye                                S      0336       5.6745       $348.80     $139.51        $69.76
70552    Mri brain w/dye                                  S      0284       6.1231       $376.37     $148.40        $75.27
70553    Mri brain w/o & w/dye                            S      0337       8.1155       $498.84     $199.53        $99.77
70554    Fmri brain by tech                       NI      S      0336       5.6745       $348.80     $139.51        $69.76
70555    Fmri brain by phys/psych                 NI      S      0336       5.6745       $348.80     $139.51        $69.76
70557    Mri brain w/o dye                                S      0336       5.6745       $348.80     $139.51        $69.76
70558    Mri brain w/dye                                  S      0284       6.1231       $376.37     $148.40        $75.27
70559    Mri brain w/o & w/dye                            S      0337       8.1155       $498.84     $199.53        $99.77
71010    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71015    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71020    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71021    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71022    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71023    Chest x-ray and fluoroscopy                      X      0272       1.2908        $79.34      $31.64        $15.87
71030    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71034    Chest x-ray and fluoroscopy                      X      0272       1.2908        $79.34      $31.64        $15.87
71035    Chest x-ray                                      X      0260       0.7093        $43.60                     $8.72
71040    Contrast x-ray of bronchi                        X      0263       1.6956       $104.23      $23.77        $20.85
71060    Contrast x-ray of bronchi                        X      0263       1.6956       $104.23      $23.77        $20.85
71090    X-ray & pacemaker insertion                      X      0272       1.2908        $79.34      $31.64        $15.87
71100    X-ray exam of ribs                               X        Milliman 0.7093
                                                                 0260                     $43.60                     $8.72
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
71101    X-ray exam of ribs/chest                         X      0260            0.7093           43.6                   8.72
71110    X-ray exam of ribs                               X      0260            0.7093        $43.60                  $8.72
71111    X-ray exam of ribs/chest                         X      0261            1.2224        $75.14                 $15.03
71120    X-ray exam of breastbone                         X      0260            0.7093        $43.60                  $8.72
71130    X-ray exam of breastbone                         X      0260            0.7093           43.6                   8.72
71250    Ct thorax w/o dye                                S      0332            3.0908       $189.99      $75.24     $38.00
71260    Ct thorax w/dye                                  S      0283            4.0825       $250.94     $100.37     $50.19
71270    Ct thorax w/o & w/dye                            S      0333            4.8405       $297.54     $119.01     $59.51
71275    Ct angiography, chest                            S      0662            4.8552       $298.44     $118.88     $59.69
71550    Mri chest w/o dye                                S      0336            5.6745       $348.80     $139.51     $69.76
71551    Mri chest w/dye                                  S      0284            6.1231         376.37       148.4      75.27
71552    Mri chest w/o & w/dye                            S      0337            8.1155         498.84      199.53      99.77
71555    Mri angio chest w or w/o dye                     B
72010    X-ray exam of spine                              X      0260            0.7093       $43.60                           $8.72
72020    X-ray exam of spine                              X      0260            0.7093       $43.60                           $8.72
72040    X-ray exam of neck spine                         X      0260            0.7093       $43.60                           $8.72
72050    X-ray exam of neck spine                         X      0261            1.2224       $75.14                          $15.03
72052    X-ray exam of neck spine                         X      0261            1.2224       $75.14                          $15.03
72069    X-ray exam of trunk spine                        X      0260            0.7093       $43.60                           $8.72
72070    X-ray exam of thoracic spine                     X      0260            0.7093       $43.60                           $8.72
72072    X-ray exam of thoracic spine                     X      0260            0.7093       $43.60                           $8.72
72074    X-ray exam of thoracic spine                     X      0260            0.7093       $43.60                           $8.72
72080    X-ray exam of trunk spine                        X      0260            0.7093       $43.60                           $8.72
72090    X-ray exam of trunk spine                        X      0261            1.2224       $75.14                          $15.03
72100    X-ray exam of lower spine                        X      0260            0.7093          43.6                            8.72
72110    X-ray exam of lower spine                        X      0261            1.2224       $75.14                          $15.03
72114    X-ray exam of lower spine                        X      0261            1.2224       $75.14                          $15.03
72120    X-ray exam of lower spine                        X      0261            1.2224       $75.14                          $15.03
72125    Ct neck spine w/o dye                            S      0332            3.0908      $189.99          $75.24          $38.00
72126    Ct neck spine w/dye                              S      0283            4.0825      $250.94         $100.37          $50.19
72127    Ct neck spine w/o & w/dye                        S      0333            4.8405      $297.54         $119.01          $59.51
72128    Ct chest spine w/o dye                           S      0332            3.0908        189.99           75.24              38
72129    Ct chest spine w/dye                             S      0283            4.0825        250.94          100.37           50.19
72130    Ct chest spine w/o & w/dye                       S      0333            4.8405        297.54          119.01           59.51
72131    Ct lumbar spine w/o dye                          S      0332            3.0908      $189.99          $75.24          $38.00
72132    Ct lumbar spine w/dye                            S      0283            4.0825      $250.94         $100.37          $50.19
72133    Ct lumbar spine w/o & w/dye                      S      0333            4.8405      $297.54         $119.01          $59.51
72141    Mri neck spine w/o dye                           S      0336            5.6745      $348.80         $139.51          $69.76
72142    Mri neck spine w/dye                             S      0284            6.1231      $376.37         $148.40          $75.27
72146    Mri chest spine w/o dye                          S      0336            5.6745      $348.80         $139.51          $69.76
72147    Mri chest spine w/dye                            S      0284            6.1231      $376.37            148.4         $75.27
72148    Mri lumbar spine w/o dye                         S      0336            5.6745      $348.80           139.51         $69.76
72149    Mri lumbar spine w/dye                           S      0284            6.1231      $376.37            148.4         $75.27
72156    Mri neck spine w/o & w/dye                       S      0337            8.1155      $498.84         $199.53          $99.77
72157    Mri chest spine w/o & w/dye                      S      0337            8.1155        498.84          199.53           99.77
72158    Mri lumbar spine w/o & w/dye                     S      0337            8.1155      $498.84         $199.53          $99.77
72159    Mr angio spine w/o&w/dye                         E
72170    X-ray exam of pelvis                             X      0260       0.7093            $43.60                           $8.72
72190    X-ray exam of pelvis                             X      0260       0.7093            $43.60                           $8.72
72191    Ct angiograph pelv w/o&w/dye                     S      0662       4.8552           $298.44         $118.88          $59.69
72192    Ct pelvis w/o dye                                S      0332       3.0908             189.99           75.24              38
72193    Ct pelvis w/dye                                  S      0283       4.0825           $250.94         $100.37          $50.19
72194    Ct pelvis w/o & w/dye                            S        Milliman 4.8405
                                                                 0333                        $297.54         $119.01          $59.51
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 94 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                    National   Minimum
HCPCS/                                                                         Relative            Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate Copayment Copayment
72195    Mri pelvis w/o dye                               S      0336            5.6745   $348.80     $139.51     $69.76
72196    Mri pelvis w/dye                                 S      0284            6.1231   $376.37     $148.40     $75.27
72197    Mri pelvis w/o & w/dye                           S      0337            8.1155     498.84      199.53      99.77
72198    Mr angio pelvis w/o & w/dye                      B
72200    X-ray exam sacroiliac joints                     X      0260            0.7093        43.6                             8.72
72202    X-ray exam sacroiliac joints                     X      0260            0.7093     $43.60                            $8.72
72220    X-ray exam of tailbone                           X      0260            0.7093     $43.60                            $8.72
72240    Contrast x-ray of neck spine                     S      0274            2.5544    $157.01          $62.80           $31.40
72255    Contrast x-ray, thorax spine                     S      0274            2.5544    $157.01             62.8          $31.40
72265    Contrast x-ray, lower spine                      S      0274            2.5544    $157.01          $62.80           $31.40
72270    Contrast x-ray, spine                            S      0274            2.5544    $157.01          $62.80           $31.40
72275    Epidurography                                    S      0274            2.5544    $157.01          $62.80           $31.40
72285    X-ray c/t spine disk                             S      0388           15.9758    $982.00         $289.72          $196.40
72291    Perq vertebroplasty, fluor               NI      S      0274            2.5544      157.01            62.8             31.4
72292    Perq vertebroplasty, ct                  NI      S      0274            2.5544    $157.01          $62.80           $31.40
72295    X-ray of lower spine disk                        S      0388           15.9758         982          289.72            196.4
73000    X-ray exam of collar bone                        X      0260            0.7093     $43.60                            $8.72
73010    X-ray exam of shoulder blade                     X      0260            0.7093     $43.60                            $8.72
73020    X-ray exam of shoulder                           X      0260            0.7093        43.6                             8.72
73030    X-ray exam of shoulder                           X      0260            0.7093     $43.60                            $8.72
73040    Contrast x-ray of shoulder                       S      0275            3.6915    $226.91             $69.09        $45.38
73050    X-ray exam of shoulders                          X      0260            0.7093     $43.60                            $8.72
73060    X-ray exam of humerus                            X      0260            0.7093        43.6                             8.72
73070    X-ray exam of elbow                              X      0260            0.7093        43.6                             8.72
73080    X-ray exam of elbow                              X      0260            0.7093        43.6                             8.72
73085    Contrast x-ray of elbow                          S      0275            3.6915    $226.91             $69.09        $45.38
73090    X-ray exam of forearm                            X      0260            0.7093        43.6                             8.72
73092    X-ray exam of arm, infant                        X      0260            0.7093     $43.60                            $8.72
73100    X-ray exam of wrist                              X      0260            0.7093     $43.60                            $8.72
73110    X-ray exam of wrist                              X      0260            0.7093     $43.60                            $8.72
73115    Contrast x-ray of wrist                          S      0275            3.6915    $226.91             $69.09        $45.38
73120    X-ray exam of hand                               X      0260            0.7093     $43.60                            $8.72
73130    X-ray exam of hand                               X      0260            0.7093     $43.60                            $8.72
73140    X-ray exam of finger(s)                          X      0260            0.7093     $43.60                            $8.72
73200    Ct upper extremity w/o dye                       S      0332            3.0908    $189.99          $75.24           $38.00
73201    Ct upper extremity w/dye                         S      0283            4.0825    $250.94         $100.37           $50.19
73202    Ct uppr extremity w/o&w/dye                      S      0333            4.8405    $297.54         $119.01           $59.51
73206    Ct angio upr extrm w/o&w/dye                     S      0662            4.8552    $298.44         $118.88           $59.69
73218    Mri upper extremity w/o dye                      S      0336            5.6745    $348.80         $139.51           $69.76
73219    Mri upper extremity w/dye                        S      0284            6.1231    $376.37         $148.40           $75.27
73220    Mri uppr extremity w/o&w/dye                     S      0337            8.1155    $498.84         $199.53           $99.77
73221    Mri joint upr extrem w/o dye                     S      0336            5.6745    $348.80         $139.51           $69.76
73222    Mri joint upr extrem w/dye                       S      0284            6.1231    $376.37         $148.40           $75.27
73223    Mri joint upr extr w/o&w/dye                     S      0337            8.1155    $498.84         $199.53           $99.77
73225    Mr angio upr extr w/o&w/dye                      E
73500    X-ray exam of hip                                X      0260       0.7093          $43.60                             $8.72
73510    X-ray exam of hip                                X      0260       0.7093          $43.60                             $8.72
73520    X-ray exam of hips                               X      0261       1.2224          $75.14                            $15.03
73525    Contrast x-ray of hip                            S      0275       3.6915         $226.91             $69.09         $45.38
73530    X-ray exam of hip                                X      0261       1.2224          $75.14                            $15.03
73540    X-ray exam of pelvis & hips                      X      0260       0.7093          $43.60                             $8.72
73542    X-ray exam, sacroiliac joint                     S      0275       3.6915         $226.91             $69.09         $45.38
73550    X-ray exam of thigh                              X        Milliman 0.7093
                                                                 0260                       $43.60                             $8.72
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 95 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
73560    X-ray exam of knee, 1 or 2                       X      0260            0.7093        $43.60                  $8.72
73562    X-ray exam of knee, 3                            X      0260            0.7093        $43.60                  $8.72
73564    X-ray exam, knee, 4 or more                      X      0260            0.7093        $43.60                  $8.72
73565    X-ray exam of knees                              X      0260            0.7093        $43.60                  $8.72
73580    Contrast x-ray of knee joint                     S      0275            3.6915       $226.91      $69.09     $45.38
73590    X-ray exam of lower leg                          X      0260            0.7093        $43.60                  $8.72
73592    X-ray exam of leg, infant                        X      0260            0.7093        $43.60                  $8.72
73600    X-ray exam of ankle                              X      0260            0.7093        $43.60                  $8.72
73610    X-ray exam of ankle                              X      0260            0.7093        $43.60                  $8.72
73615    Contrast x-ray of ankle                          S      0275            3.6915       $226.91      $69.09     $45.38
73620    X-ray exam of foot                               X      0260            0.7093        $43.60                  $8.72
73630    X-ray exam of foot                               X      0260            0.7093        $43.60                  $8.72
73650    X-ray exam of heel                               X      0260            0.7093        $43.60                  $8.72
73660    X-ray exam of toe(s)                             X      0260            0.7093        $43.60                  $8.72
73700    Ct lower extremity w/o dye                       S      0332            3.0908       $189.99      $75.24     $38.00
73701    Ct lower extremity w/dye                         S      0283            4.0825       $250.94     $100.37     $50.19
73702    Ct lwr extremity w/o&w/dye                       S      0333            4.8405       $297.54     $119.01     $59.51
73706    Ct angio lwr extr w/o&w/dye                      S      0662            4.8552       $298.44     $118.88     $59.69
73718    Mri lower extremity w/o dye                      S      0336            5.6745       $348.80     $139.51     $69.76
73719    Mri lower extremity w/dye                        S      0284            6.1231       $376.37        148.4    $75.27
73720    Mri lwr extremity w/o&w/dye                      S      0337            8.1155       $498.84       199.53    $99.77
73721    Mri jnt of lwr extre w/o dye                     S      0336            5.6745       $348.80       139.51    $69.76
73722    Mri joint of lwr extr w/dye                      S      0284            6.1231       $376.37        148.4    $75.27
73723    Mri joint lwr extr w/o&w/dye                     S      0337            8.1155       $498.84       199.53    $99.77
73725    Mr ang lwr ext w or w/o dye                      B
74000    X-ray exam of abdomen                            X      0260            0.7093       $43.60                              $8.72
74010    X-ray exam of abdomen                            X      0260            0.7093       $43.60                              $8.72
74020    X-ray exam of abdomen                            X      0260            0.7093       $43.60                              $8.72
74022    X-ray exam series, abdomen                       X      0261            1.2224       $75.14                             $15.03
74150    Ct abdomen w/o dye                               S      0332            3.0908      $189.99          $75.24             $38.00
74160    Ct abdomen w/dye                                 S      0283            4.0825      $250.94         $100.37             $50.19
74170    Ct abdomen w/o & w/dye                           S      0333            4.8405      $297.54         $119.01             $59.51
74175    Ct angio abdom w/o & w/dye                       S      0662            4.8552      $298.44         $118.88             $59.69
74181    Mri abdomen w/o dye                              S      0336            5.6745      $348.80         $139.51             $69.76
74182    Mri abdomen w/dye                                S      0284            6.1231        376.37           148.4              75.27
74183    Mri abdomen w/o & w/dye                          S      0337            8.1155        498.84          199.53              99.77
74185    Mri angio, abdom w orw/o dye                     B
74190    X-ray exam of peritoneum                         X      0264       2.9586           $181.86             $70.27          $36.37
74210    Contrst x-ray exam of throat                     S      0276       1.4294            $87.86             $34.97          $17.57
74220    Contrast x-ray, esophagus                        S      0276       1.4294            $87.86             $34.97          $17.57
74230    Cine/vid x-ray, throat/esoph                     S      0276       1.4294            $87.86             $34.97          $17.57
74235    Remove esophagus obstruction             CH      S      0257       1.0974              67.45                              13.49
74240    X-ray exam, upper gi tract                       S      0276       1.4294            $87.86             $34.97          $17.57
74241    X-ray exam, upper gi tract                       S      0276       1.4294            $87.86               34.97         $17.57
74245    X-ray exam, upper gi tract                       S      0277       2.2176           $136.31             $54.52          $27.26
74246    Contrst x-ray uppr gi tract                      S      0276       1.4294            $87.86             $34.97          $17.57
74247    Contrst x-ray uppr gi tract                      S      0276       1.4294            $87.86             $34.97          $17.57
74249    Contrst x-ray uppr gi tract                      S      0277       2.2176           $136.31             $54.52          $27.26
74250    X-ray exam of small bowel                        S      0276       1.4294            $87.86             $34.97          $17.57
74251    X-ray exam of small bowel                        S      0277       2.2176           $136.31             $54.52          $27.26
74260    X-ray exam of small bowel                CH      S      0276       1.4294            $87.86             $34.97          $17.57
74270    Contrast x-ray exam of colon                     S      0276       1.4294            $87.86             $34.97          $17.57
74280    Contrast x-ray exam of colon                     S        Milliman 2.2176
                                                                 0277                        $136.31             $54.52          $27.26
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                         Page 96 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
74283    Contrast x-ray exam of colon                     S      0276            1.4294        $87.86      $34.97     $17.57
74290    Contrast x-ray, gallbladder                      S      0276            1.4294        $87.86      $34.97     $17.57
74291    Contrast x-rays, gallbladder                     S      0276            1.4294        $87.86      $34.97     $17.57
74300    X-ray bile ducts/pancreas                        X      0263            1.6956       $104.23      $23.77     $20.85
74301    X-rays at surgery add-on                         X      0263            1.6956       $104.23      $23.77     $20.85
74305    X-ray bile ducts/pancreas                        X      0263            1.6956       $104.23        23.77    $20.85
74320    Contrast x-ray of bile ducts                     X      0264            2.9586       $181.86        70.27    $36.37
74327    X-ray bile stone removal                         S      0296            2.6802       $164.75        53.99    $32.95
74328    X-ray bile duct endoscopy                        N
74329    X-ray for pancreas endoscopy                     N
74330    X-ray bile/panc endoscopy                        N
74340    X-ray guide for GI tube                          X      0272            1.2908       $79.34               31.64          $15.87
74350    X-ray guide, stomach tube                        X      0263            1.6956      $104.23               23.77          $20.85
74355    X-ray guide, intestinal tube                     X      0263            1.6956      $104.23               23.77          $20.85
74360    X-ray guide, GI dilation                 CH      S      0257            1.0974       $67.45                              $13.49
74363    X-ray, bile duct dilation                        S      0297            3.6392      $223.69                89.47         $44.74
74400    Contrst x-ray, urinary tract                     S      0278            2.4159      $148.50                 59.4         $29.70
74410    Contrst x-ray, urinary tract                     S      0278            2.4159      $148.50                 59.4         $29.70
74415    Contrst x-ray, urinary tract                     S      0278            2.4159      $148.50              $59.40          $29.70
74420    Contrst x-ray, urinary tract                     S      0278            2.4159      $148.50                 59.4         $29.70
74425    Contrst x-ray, urinary tract                     S      0278            2.4159         148.5                59.4            29.7
74430    Contrast x-ray, bladder                          S      0278            2.4159         148.5                59.4            29.7
74440    X-ray, male genital tract                        S      0278            2.4159         148.5                59.4            29.7
74445    X-ray exam of penis                              S      0278            2.4159      $148.50                 59.4         $29.70
74450    X-ray, urethra/bladder                           S      0278            2.4159         148.5                59.4            29.7
74455    X-ray, urethra/bladder                           S      0278            2.4159      $148.50                 59.4         $29.70
74470    X-ray exam of kidney lesion                      X      0263            1.6956      $104.23                23.77         $20.85
74475    X-ray control, cath insert                       S      0297            3.6392      $223.69                89.47         $44.74
74480    X-ray control, cath insert                       S      0296            2.6802      $164.75                53.99         $32.95
74485    X-ray guide, GU dilation                         S      0296            2.6802      $164.75              $53.99          $32.95
74710    X-ray measurement of pelvis                      X      0261            1.2224       $75.14                              $15.03
74740    X-ray, female genital tract                      X      0264            2.9586      $181.86              $70.27          $36.37
74742    X-ray, fallopian tube                            X      0264            2.9586      $181.86              $70.27          $36.37
74775    X-ray exam of perineum                           S      0278            2.4159      $148.50              $59.40          $29.70
75552    Heart mri for morph w/o dye                      S      0336            5.6745      $348.80               139.51         $69.76
75553    Heart mri for morph w/dye                        S      0284            6.1231      $376.37                148.4         $75.27
75554    Cardiac MRI/function                             S      0336            5.6745      $348.80               139.51         $69.76
75555    Cardiac MRI/limited study                        S      0336            5.6745      $348.80               139.51         $69.76
75556    Cardiac MRI/flow mapping                         E
75600    Contrast x-ray exam of aorta                     S      0280     20.8225           $1,279.92           353.85          $255.98
75605    Contrast x-ray exam of aorta                     S      0280     20.8225           $1,279.92           353.85          $255.98
75625    Contrast x-ray exam of aorta                     S      0280     20.8225           $1,279.92           353.85          $255.98
75630    X-ray aorta, leg arteries                        S      0280     20.8225           $1,279.92           353.85          $255.98
75635    Ct angio abdominal arteries                      S      0662       4.8552            $298.44           118.88           $59.69
75650    Artery x-rays, head & neck                       S      0280     20.8225           $1,279.92           353.85          $255.98
75658    Artery x-rays, arm                               S      0279       9.5061            $584.32           150.03          $116.86
75660    Artery x-rays, head & neck                       S      0668       6.2463              383.95           88.26             76.79
75662    Artery x-rays, head & neck                       S      0280     20.8225           $1,279.92           353.85          $255.98
75665    Artery x-rays, head & neck                       S      0280     20.8225           $1,279.92         $353.85           $255.98
75671    Artery x-rays, head & neck                       S      0280     20.8225           $1,279.92         $353.85           $255.98
75676    Artery x-rays, neck                              S      0280     20.8225           $1,279.92         $353.85           $255.98
75680    Artery x-rays, neck                              S      0280     20.8225           $1,279.92         $353.85           $255.98
75685    Artery x-rays, spine                             S      0280     20.8225
                                                                   Milliman                 $1,279.92         $353.85           $255.98
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                          Page 97 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
75705    Artery x-rays, spine                             S      0668            6.2463       $383.95      $88.26               $76.79
75710    Artery x-rays, arm/leg                           S      0280           20.8225     $1,279.92     $353.85              $255.98
75716    Artery x-rays, arms/legs                         S      0280           20.8225     $1,279.92     $353.85              $255.98
75722    Artery x-rays, kidney                            S      0280           20.8225     $1,279.92     $353.85              $255.98
75724    Artery x-rays, kidneys                           S      0280           20.8225     $1,279.92     $353.85              $255.98
75726    Artery x-rays, abdomen                           S      0280           20.8225     $1,279.92     $353.85              $255.98
75731    Artery x-rays, adrenal gland                     S      0280           20.8225     $1,279.92     $353.85              $255.98
75733    Artery x-rays, adrenals                          S      0668            6.2463       $383.95      $88.26               $76.79
75736    Artery x-rays, pelvis                            S      0280           20.8225     $1,279.92     $353.85              $255.98
75741    Artery x-rays, lung                              S      0279            9.5061       $584.32     $150.03              $116.86
75743    Artery x-rays, lungs                             S      0280           20.8225     $1,279.92     $353.85              $255.98
75746    Artery x-rays, lung                              S      0279            9.5061       $584.32     $150.03              $116.86
75756    Artery x-rays, chest                             S      0279            9.5061       $584.32     $150.03              $116.86
75774    Artery x-ray, each vessel                        S      0279            9.5061       $584.32     $150.03              $116.86
75790    Visualize A-V shunt                              S      0279            9.5061       $584.32     $150.03              $116.86
75801    Lymph vessel x-ray, arm/leg                      X      0264            2.9586       $181.86      $70.27               $36.37
75803    Lymph vessel x-ray,arms/legs                     X      0264            2.9586       $181.86      $70.27               $36.37
75805    Lymph vessel x-ray, trunk                        X      0264            2.9586       $181.86      $70.27               $36.37
75807    Lymph vessel x-ray, trunk                        X      0264            2.9586       $181.86      $70.27               $36.37
75809    Nonvascular shunt, x-ray                         X      0263            1.6956       $104.23      $23.77               $20.85
75810    Vein x-ray, spleen/liver                         S      0279            9.5061       $584.32     $150.03              $116.86
75820    Vein x-ray, arm/leg                              S      0668            6.2463       $383.95      $88.26               $76.79
75822    Vein x-ray, arms/legs                            S      0668            6.2463       $383.95      $88.26               $76.79
75825    Vein x-ray, trunk                                S      0279            9.5061       $584.32     $150.03              $116.86
75827    Vein x-ray, chest                                S      0279            9.5061       $584.32     $150.03              $116.86
75831    Vein x-ray, kidney                               S      0279            9.5061       $584.32     $150.03              $116.86
75833    Vein x-ray, kidneys                              S      0279            9.5061       $584.32     $150.03              $116.86
75840    Vein x-ray, adrenal gland                        S      0280           20.8225     $1,279.92     $353.85              $255.98
75842    Vein x-ray, adrenal glands                       S      0280           20.8225     $1,279.92     $353.85              $255.98
75860    Vein x-ray, neck                                 S      0668            6.2463       $383.95      $88.26               $76.79
75870    Vein x-ray, skull                                S      0668            6.2463       $383.95      $88.26               $76.79
75872    Vein x-ray, skull                                S      0279            9.5061       $584.32     $150.03              $116.86
75880    Vein x-ray, eye socket                           S      0668            6.2463       $383.95      $88.26               $76.79
75885    Vein x-ray, liver                                S      0280           20.8225     $1,279.92     $353.85              $255.98
75887    Vein x-ray, liver                                S      0279            9.5061       $584.32     $150.03              $116.86
75889    Vein x-ray, liver                                S      0280           20.8225     $1,279.92     $353.85              $255.98
75891    Vein x-ray, liver                                S      0279            9.5061       $584.32     $150.03              $116.86
75893    Venous sampling by catheter              CH      Q      0668            6.2463       $383.95      $88.26               $76.79
75894    X-rays, transcath therapy                CH      S      0298            8.3906       $515.75     $206.30              $103.15
75896    X-rays, transcath therapy                CH      S      0298            8.3906       $515.75     $206.30              $103.15
75898    Follow-up angiography                            X      0263            1.6956       $104.23      $23.77               $20.85
75900    Intravascular cath exchange                      C
75901    Remove cva device obstruct                       X      0263            1.6956      $104.23             $23.77          $20.85
75902    Remove cva lumen obstruct                        X      0263            1.6956      $104.23             $23.77          $20.85
75940    X-ray placement, vein filter             CH      S      0298            8.3906        515.75              206.3          103.15
75945    Intravascular us                                 S      0267            2.4606        151.25               60.5           30.25
75946    Intravascular us add-on                          S      0266            1.5607       $95.93             $37.80          $19.19
75952    Endovasc repair abdom aorta                      C
75953    Abdom aneurysm endovas rpr                       C
75954    Iliac aneurysm endovas rpr                       C
75956    Xray, endovasc thor ao repr                      C
75957    Xray, endovasc thor ao repr                      C
75958    Xray, place prox ext thor ao                     C        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment             Copayment
75959    Xray, place dist ext thor ao                     C
75960    Transcath iv stent rs&i                          S      0668            6.2463       $383.95             $88.26          $76.79
75961    Retrieval, broken catheter                       S      0668            6.2463       $383.95             $88.26          $76.79
75962    Repair arterial blockage                         S      0668            6.2463       $383.95             $88.26          $76.79
75964    Repair artery blockage, each                     S      0668            6.2463       $383.95             $88.26          $76.79
75966    Repair arterial blockage                         S      0668            6.2463       $383.95             $88.26          $76.79
75968    Repair artery blockage, each                     S      0668            6.2463       $383.95               88.26         $76.79
75970    Vascular biopsy                                  S      0668            6.2463         383.95              88.26           76.79
75978    Repair venous blockage                           S      0668            6.2463       $383.95             $88.26          $76.79
75980    Contrast xray exam bile duct                     S      0297            3.6392       $223.69             $89.47          $44.74
75982    Contrast xray exam bile duct                     S      0297            3.6392       $223.69             $89.47          $44.74
75984    Xray control catheter change                     X      0263            1.6956       $104.23             $23.77          $20.85
75989    Abscess drainage under x-ray                     N
75992    Atherectomy, x-ray exam                  CH      S      0668            6.2463       $383.95             $88.26          $76.79
75993    Atherectomy, x-ray exam                  CH      S      0668            6.2463       $383.95             $88.26          $76.79
75994    Atherectomy, x-ray exam                  CH      S      0668            6.2463       $383.95             $88.26          $76.79
75995    Atherectomy, x-ray exam                  CH      S      0668            6.2463       $383.95               88.26           76.79
75996    Atherectomy, x-ray exam                  CH      S      0668            6.2463       $383.95             $88.26          $76.79
75998    Fluoroguide for vein device              CH      D
76000    Fluoroscope examination                          X      0272            1.2908        $79.34             $31.64          $15.87
76001    Fluoroscope exam, extensive                      N
76003    Needle localization by x-ray             CH      D
76005    Fluoroguide for spine inject             CH      D
76006    X-ray stress view                        CH      D
76010    X-ray, nose to rectum                            X      0260            0.7093        $43.60                                 $8.72
76012    Percut vertebroplasty fluor              CH      D
76013    Percut vertebroplasty, ct                CH      D
76020    X-rays for bone age                      CH      D
76040    X-rays, bone evaluation                  CH      D
76061    X-rays, bone survey                      CH      D
76062    X-rays, bone survey                      CH      D
76065    X-rays, bone evaluation                  CH      D
76066    Joint survey, single view                CH      D
76070    Ct bone density, axial                   CH      D
76071    Ct bone density, peripheral              CH      D
76075    Dxa bone density, axial                  CH      D
76076    Dxa bone density/peripheral              CH      D
76077    Dxa bone density/v-fracture              CH      D
76078    Radiographic absorptiometry              CH      D
76080    X-ray exam of fistula                            X      0263            1.6956       $104.23             $23.77          $20.85
76082    Computer mammogram add-on                CH      D
76083    Computer mammogram add-on                CH      D
76086    X-ray of mammary duct                    CH      D
76088    X-ray of mammary ducts                   CH      D
76090    Mammogram, one breast                    CH      D
76091    Mammogram, both breasts                  CH      D
76092    Mammogram, screening                     CH      D
76093    Magnetic image, breast                   CH      D
76094    Magnetic image, both breasts             CH      D
76095    Stereotactic breast biopsy               CH      D
76096    X-ray of needle wire, breast             CH      D
76098    X-ray exam, breast specimen                      X      0260       0.7093               43.6                                   8.72
76100    X-ray exam of body section                       X        Milliman 1.2224
                                                                 0261                           75.14                                  15.03
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                          Page 99 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
76101    Complex body section x-ray                       X      0263            1.6956       $104.23      $23.77               $20.85
76102    Complex body section x-rays                      X      0264            2.9586       $181.86      $70.27               $36.37
76120    Cine/video x-rays                                X      0272            1.2908        $79.34      $31.64               $15.87
76125    Cine/video x-rays add-on                         X      0260            0.7093        $43.60                            $8.72
76140    X-ray consultation                               E
76150    X-ray exam, dry process                          X      0260            0.7093        $43.60                                $8.72
76350    Special x-ray contrast study                     N
76355    Ct scan for localization                 CH      D
76360    Ct scan for needle biopsy                CH      D
76362    Ct guide for tissue ablation             CH      D
76370    Ct scan for therapy guide                CH      D
76376    3d render w/o postprocess                        X      0340            0.6102        $37.51                             $7.50
76377    3d rendering w/postprocess                       S      0282            1.5379        $94.53            $37.81          $18.91
76380    CAT scan follow-up study                         S      0282            1.5379        $94.53            $37.81          $18.91
76390    Mr spectroscopy                                  E
76393    Mr guidance for needle place             CH      D
76394    Mri for tissue ablation                  CH      D
76400    Magnetic image, bone marrow              CH      D
76496    Fluoroscopic procedure                           X      0272            1.2908       $79.34          $31.64             $15.87
76497    Ct procedure                                     S      0282            1.5379       $94.53          $37.81             $18.91
76498    Mri procedure                                    S      0335            4.5523      $279.82         $111.92             $55.96
76499    Radiographic procedure                           X      0260            0.7093       $43.60                              $8.72
76506    Echo exam of head                                S      0265            0.9923       $60.99             $23.63          $12.20
76510    Ophth us, b & quant a                            S      0266            1.5607       $95.93             $37.80          $19.19
76511    Ophth us, quant a only                           S      0266            1.5607       $95.93             $37.80          $19.19
76512    Ophth us, b w/non-quant a                        S      0266            1.5607       $95.93             $37.80          $19.19
76513    Echo exam of eye, water bath                     S      0266            1.5607       $95.93             $37.80          $19.19
76514    Echo exam of eye, thickness                      X      0340            0.6102       $37.51                              $7.50
76516    Echo exam of eye                                 S      0265            0.9923       $60.99             $23.63          $12.20
76519    Echo exam of eye                                 S      0266            1.5607       $95.93             $37.80          $19.19
76529    Echo exam of eye                                 S      0265            0.9923         60.99              23.63            12.2
76536    Us exam of head and neck                         S      0266            1.5607         95.93               37.8           19.19
76604    Us exam, chest                           CH      S      0265            0.9923         60.99              23.63            12.2
76645    Us exam, breast(s)                               S      0265            0.9923         60.99              23.63            12.2
76700    Us exam, abdom, complete                         S      0266            1.5607       $95.93             $37.80          $19.19
76705    Echo exam of abdomen                             S      0266            1.5607       $95.93             $37.80          $19.19
76770    Us exam abdo back wall, comp                     S      0266            1.5607       $95.93             $37.80          $19.19
76775    Us exam abdo back wall, lim                      S      0266            1.5607       $95.93             $37.80          $19.19
76776    Us exam k transpl w/doppler              NI      S      0266            1.5607       $95.93             $37.80          $19.19
76778    Us exam kidney transplant                CH      D
76800    Us exam, spinal canal                            S      0266       1.5607            $95.93             $37.80          $19.19
76801    Ob us < 14 wks, single fetus                     S      0266       1.5607            $95.93             $37.80          $19.19
76802    Ob us < 14 wks, addÆl fetus                      S      0265       0.9923            $60.99             $23.63          $12.20
76805    Ob us >/= 14 wks, sngl fetus                     S      0266       1.5607            $95.93             $37.80          $19.19
76810    Ob us >/= 14 wks, addl fetus                     S      0266       1.5607            $95.93             $37.80          $19.19
76811    Ob us, detailed, sngl fetus                      S      0267       2.4606           $151.25             $60.50          $30.25
76812    Ob us, detailed, addl fetus              CH      S      0265       0.9923              60.99              23.63            12.2
76813    Ob us nuchal meas, 1 gest                NI      S      0266       1.5607            $95.93             $37.80          $19.19
76814    Ob us nuchal meas, add-on                NI      S      0265       0.9923              60.99              23.63            12.2
76815    Ob us, limited, fetus(s)                         S      0265       0.9923              60.99              23.63            12.2
76816    Ob us, follow-up, per fetus                      S      0265       0.9923              60.99              23.63            12.2
76817    Transvaginal us, obstetric               CH      S      0265       0.9923              60.99              23.63            12.2
76818    Fetal biophys profile w/nst                      S        Milliman 1.5607
                                                                 0266                           95.93               37.8           19.19
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                       National   Minimum
HCPCS/                                                                         Relative               Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate    Copayment Copayment
76819    Fetal biophys profil w/o nst                     S      0266            1.5607     95.93            37.8      19.19
76820    Umbilical artery echo                            S      0096            1.5303     94.06           37.62      18.81
76821    Middle cerebral artery echo                      S      0096            1.5303     94.06           37.62      18.81
76825    Echo exam of fetal heart                 CH      S      0697            1.5973     98.18           35.99      19.64
76826    Echo exam of fetal heart                         S      0697            1.5973     98.18           35.99      19.64
76827    Echo exam of fetal heart                 CH      S      0697            1.5973     98.18           35.99      19.64
76828    Echo exam of fetal heart                         S      0697            1.5973     98.18           35.99      19.64
76830    Transvaginal us, non-ob                          S      0266            1.5607     95.93            37.8      19.19
76831    Echo exam, uterus                                S      0267            2.4606    151.25            60.5      30.25
76856    Us exam, pelvic, complete                        S      0266            1.5607     95.93            37.8      19.19
76857    Us exam, pelvic, limited                         S      0265            0.9923     60.99           23.63       12.2
76870    Us exam, scrotum                                 S      0266            1.5607     95.93            37.8      19.19
76872    Us, transrectal                                  S      0266            1.5607     95.93            37.8      19.19
76873    Echograp trans r, pros study                     S      0266            1.5607     95.93            37.8      19.19
76880    Us exam, extremity                               S      0266            1.5607     95.93            37.8      19.19
76885    Us exam infant hips, dynamic                     S      0265            0.9923     60.99           23.63       12.2
76886    Us exam infant hips, static              CH      S      0265            0.9923     60.99           23.63       12.2
76930    Echo guide, cardiocentesis                       S      0268            1.1882     73.04                      14.61
76932    Echo guide for heart biopsy              CH      S      0309            2.1012    129.16                      25.83
76936    Echo guide for artery repair             CH      S      0309            2.1012    129.16                      25.83
76937    Us guide, vascular access                        N
76940    Us guide, tissue ablation                        S      0268            1.1882      73.04                               14.61
76941    Echo guide for transfusion                       S      0268            1.1882      73.04                               14.61
76942    Echo guide for biopsy                            S      0268            1.1882      73.04                               14.61
76945    Echo guide, villus sampling                      S      0268            1.1882      73.04                               14.61
76946    Echo guide for amniocentesis                     S      0268            1.1882      73.04                               14.61
76948    Echo guide, ova aspiration               CH      S      0309            2.1012     129.16                               25.83
76950    Echo guidance radiotherapy                       S      0268            1.1882      73.04                               14.61
76965    Echo guidance radiotherapy               CH      S      0309            2.1012     129.16                               25.83
76970    Ultrasound exam follow-up                        S      0265            0.9923      60.99             23.63              12.2
76975    GI endoscopic ultrasound                         S      0266            1.5607      95.93              37.8             19.19
76977    Us bone density measure                          X      0340            0.6102      37.51                                 7.5
76986    Ultrasound guide intraoper               CH      D
76998    Us guide, intraop                        NI      S      0266            1.5607      95.93              37.8             19.19
76999    Echo examination procedure                       S      0265            0.9923      60.99             23.63              12.2
77001    Fluoroguide for vein device              NI      N
77002    Needle localization by xray              NI      N
77003    Fluoroguide for spine inject             NI      N
77011    Ct scan for localization                 NI      S      0283            4.0825     250.94            100.37             50.19
77012    Ct scan for needle biopsy                NI      S      0283            4.0825     250.94            100.37             50.19
77013    Ct guide for tissue ablation             NI      S      0333            4.8405     297.54            119.01             59.51
77014    Ct scan for therapy guide                NI      S      0282            1.5379      94.53             37.81             18.91
77021    Mr guidance for needle place             NI      S      0335            4.5523     279.82            111.92             55.96
77022    Mri for tissue ablation                  NI      S      0335            4.5523     279.82            111.92             55.96
77031    Stereotact guide for brst bx             NI      X      0264            2.9586     181.86             70.27             36.37
77032    Guidance for needle, breast              NI      X      0263            1.6956     104.23             23.77             20.85
77051    Computer dx mammogram add-on             NI      A
77052    Comp screen mammogram add-on             NI      A
77053    X-ray of mammary duct                    NI      X      0263            1.6956     104.23             23.77             20.85
77054    X-ray of mammary ducts                   NI      X      0263            1.6956     104.23             23.77             20.85
77055    Mammogram, one breast                    NI      A
77056    Mammogram, both breasts                  NI      A
77057    Mammogram, screening                     NI      A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment             Copayment
77058    Mri, one breast                          NI      B
77059    Mri, both breasts                        NI      B
77071    X-ray stress view                        NI      X      0260            0.7093           43.6                                  8.72
77072    X-rays for bone age                      NI      X      0260            0.7093           43.6                                  8.72
77073    X-rays, bone length studies              NI      X      0260            0.7093           43.6                                  8.72
77074    X-rays, bone survey, limited             NI      X      0261            1.2224          75.14                                 15.03
77075    X-rays, bone survey complete             NI      X      0261            1.2224          75.14                                 15.03
77076    X-rays, bone survey, infant              NI      X      0260            0.7093           43.6                                  8.72
77077    Joint survey, single view                NI      X      0260            0.7093           43.6                                  8.72
77078    Ct bone density, axial                   NI      S      0288            1.1755          72.26               28.9              14.45
77079    Ct bone density, peripheral              NI      S      0282            1.5379          94.53              37.81              18.91
77080    Dxa bone density, axial                  NI      S      0288            1.1755          72.26               28.9              14.45
77081    Dxa bone density/peripheral              NI      S      0665            0.5497        $33.79             $13.51              $6.76
77082    Dxa bone density, vert fx                NI      X      0260            0.7093        $43.60                                 $8.72
77083    Radiographic absorptiometry              NI      X      0261            1.2224          75.14                                 15.03
77084    Magnetic image, bone marrow              NI      S      0335            4.5523         279.82            111.92               55.96
77261    Srs, multisource                                 B
77262    Srs, linear based                                B
77263    Sbrt delivery                                    B
77280    Sbrt management                                  X      0304            1.5735         96.72              38.68           19.34
77285    Set radiation therapy field                      X      0305            3.9723        244.17              91.38           48.83
77290    Set radiation therapy field                      X      0305            3.9723        244.17              91.38           48.83
77295    Set radiation therapy field                      X      0310           13.8081        848.76             325.27          169.75
77299    Radiation therapy planning                       X      0304            1.5735         96.72              38.68           19.34
77300    Radiation therapy dose plan                      X      0304            1.5735         96.72              38.68           19.34
77301    Radiotherapy dose plan, imrt                     X      0310           13.8081        848.76             325.27          169.75
77305    Teletx isodose plan simple                       X      0304            1.5735         96.72              38.68           19.34
77310    Teletx isodose plan intermed                     X      0305            3.9723        244.17              91.38           48.83
77315    Teletx isodose plan complex                      X      0305            3.9723        244.17              91.38           48.83
77321    Special teletx port plan                         X      0305            3.9723        244.17              91.38           48.83
77326    Brachytx isodose calc simp                       X      0304            1.5735         96.72              38.68           19.34
77327    Brachytx isodose calc interm                     X      0305            3.9723        244.17              91.38           48.83
77328    Brachytx isodose plan compl                      X      0305            3.9723        244.17              91.38           48.83
77331    Special radiation dosimetry                      X      0304            1.5735         96.72              38.68           19.34
77332    Radiation treatment aid(s)                       X      0303            2.9430         180.9              66.95           36.18
77333    Radiation treatment aid(s)                       X      0303            2.9430         180.9              66.95           36.18
77334    Radiation treatment aid(s)                       X      0303            2.9430         180.9              66.95           36.18
77336    Radiation physics consult                        X      0304            1.5735         96.72              38.68           19.34
77370    Radiation physics consult                        X      0304            1.5735         96.72              38.68           19.34
77371    Srs, multisource                         NI      S      0127          138.4486       8510.16                            1702.03
77372    Srs, linear based                        NI      B
77373    Sbrt delivery                            NI      B
77399    External radiation dosimetry                     X      0304       1.5735              96.72              38.68              19.34
77401    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77402    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77403    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77404    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77406    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77407    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77408    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77409    Radiation treatment delivery                     S      0300       1.4826              91.13                                 18.23
77411    Radiation treatment delivery                     S      0301       2.2295             137.04                                 27.41
77412    Radiation treatment delivery                     S        Milliman 2.2295
                                                                 0301                          137.04                                 27.41
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
77413    Radiation treatment delivery                     S      0301            2.2295        137.04                           27.41
77414    Radiation treatment delivery                     S      0301            2.2295        137.04                           27.41
77416    Radiation treatment delivery                     S      0301            2.2295        137.04                           27.41
77417    Radiology port film(s)                           X      0260            0.7093           43.6                           8.72
77418    Radiation tx delivery, imrt                      S      0412            5.4731        336.42                           67.28
77421    Stereoscopic x-ray guidance              CH      S      0257            1.0974         67.45                           13.49
77422    Neutron beam tx, simple                          S      0301            2.2295        137.04                           27.41
77423    Neutron beam tx, complex                         S      0301            2.2295        137.04                           27.41
77427    Radiation tx management, x5                      B
77431    Radiation therapy management                     B
77432    Stereotactic radiation trmt                      B
77435    Sbrt management                          NI      N
77470    Special radiation treatment                      S      0299            5.8839        361.67                              72.33
77499    Radiation therapy management                     B
77520    Proton trmt, simple w/o comp                     S      0664           18.8926       1161.29                          232.26
77522    Proton trmt, simple w/comp                       S      0664           18.8926       1161.29                          232.26
77523    Proton trmt, intermediate                        S      0667           22.6031       1389.37                          277.87
77525    Proton treatment, complex                        S      0667           22.6031       1389.37                          277.87
77600    Hyperthermia treatment                           S      0314            3.3461        205.68            60.88          41.14
77605    Hyperthermia treatment                           S      0314            3.3461        205.68            60.88          41.14
77610    Hyperthermia treatment                           S      0314            3.3461        205.68            60.88          41.14
77615    Hyperthermia treatment                           S      0314            3.3461        205.68            60.88          41.14
77620    Hyperthermia treatment                           S      0314            3.3461        205.68            60.88          41.14
77750    Infuse radioactive materials                     S      0301            2.2295        137.04                           27.41
77761    Apply intrcav radiat simple                      S      0312            4.8569        298.54                           59.71
77762    Apply intrcav radiat interm                      S      0312            4.8569        298.54                           59.71
77763    Apply intrcav radiat compl                       S      0312            4.8569        298.54                           59.71
77776    Apply interstit radiat simpl                     S      0312            4.8569        298.54                           59.71
77777    Apply interstit radiat inter                     S      0312            4.8569        298.54                           59.71
77778    Apply interstit radiat compl                     S      0651           16.8462        1035.5                           207.1
77781    High intensity brachytherapy                     S      0313           12.8473         789.7                          157.94
77782    High intensity brachytherapy                     S      0313           12.8473         789.7                          157.94
77783    High intensity brachytherapy                     S      0313           12.8473         789.7                          157.94
77784    High intensity brachytherapy                     S      0313           12.8473         789.7                          157.94
77789    Apply surface radiation                          S      0300            1.4826         91.13                           18.23
77790    Radiation handling                               N
77799    Radium/radioisotope therapy              CH      S      0312       4.8569             298.54                              59.71
78000    Thyroid, single uptake                           S      0389       1.3754              84.54            33.81             16.91
78001    Thyroid, multiple uptakes                        S      0389       1.3754              84.54            33.81             16.91
78003    Thyroid suppress/stimul                          S      0392       2.0057             123.29            49.31             24.66
78006    Thyroid imaging with uptake                      S      0390       2.3432             144.03            57.61             28.81
78007    Thyroid image, mult uptakes                      S      0391       2.7146             166.86            66.18             33.37
78010    Thyroid imaging                                  S      0390       2.3432             144.03            57.61             28.81
78011    Thyroid imaging with flow                        S      0390       2.3432             144.03            57.61             28.81
78015    Thyroid met imaging                              S      0406       3.9934             245.47            98.18             49.09
78016    Thyroid met imaging/studies                      S      0406       3.9934             245.47            98.18             49.09
78018    Thyroid met imaging, body                        S      0406       3.9934             245.47            98.18             49.09
78020    Thyroid met uptake                               S      0399       1.5054              92.53             35.8             18.51
78070    Parathyroid nuclear imaging                      S      0391       2.7146             166.86            66.18             33.37
78075    Adrenal nuclear imaging                          S      0391       2.7146             166.86            66.18             33.37
78099    Endocrine nuclear procedure                      S      0390       2.3432             144.03            57.61             28.81
78102    Bone marrow imaging, ltd                         S      0400       3.9073             240.17            93.22             48.03
78103    Bone marrow imaging, mult                        S        Milliman 3.9073
                                                                 0400                          240.17            93.22             48.03
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                       National   Minimum
HCPCS/                                                                         Relative               Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate    Copayment Copayment
78104    Bone marrow imaging, body                        S      0400            3.9073    240.17           93.22      48.03
78110    Plasma volume, single                            S      0393            3.7562    230.89           82.04      46.18
78111    Plasma volume, multiple                          S      0393            3.7562    230.89           82.04      46.18
78120    Red cell mass, single                            S      0393            3.7562    230.89           82.04      46.18
78121    Red cell mass, multiple                          S      0393            3.7562    230.89           82.04      46.18
78122    Blood volume                                     S      0393            3.7562    230.89           82.04      46.18
78130    Red cell survival study                          S      0393            3.7562    230.89           82.04      46.18
78135    Red cell survival kinetics                       S      0393            3.7562    230.89           82.04      46.18
78140    Red cell sequestration                           S      0393            3.7562    230.89           82.04      46.18
78185    Spleen imaging                                   S      0400            3.9073    240.17           93.22      48.03
78190    Platelet survival, kinetics                      S      0392            2.0057    123.29           49.31      24.66
78191    Platelet survival                                S      0392            2.0057    123.29           49.31      24.66
78195    Lymph system imaging                             S      0400            3.9073    240.17           93.22      48.03
78199    Blood/lymph nuclear exam                         S      0400            3.9073    240.17           93.22      48.03
78201    Liver imaging                                    S      0394            4.3774    269.07          102.61      53.81
78202    Liver imaging with flow                          S      0394            4.3774    269.07          102.61      53.81
78205    Liver imaging (3D)                               S      0394            4.3774    269.07          102.61      53.81
78206    Liver image (3d) with flow                       S      0394            4.3774    269.07          102.61      53.81
78215    Liver and spleen imaging                         S      0394            4.3774    269.07          102.61      53.81
78216    Liver & spleen image/flow                        S      0394            4.3774    269.07          102.61      53.81
78220    Liver function study                             S      0394            4.3774    269.07          102.61      53.81
78223    Hepatobiliary imaging                            S      0394            4.3774    269.07          102.61      53.81
78230    Salivary gland imaging                           S      0395            3.6526    224.52           89.73       44.9
78231    Serial salivary imaging                          S      0395            3.6526    224.52           89.73       44.9
78232    Salivary gland function exam                     S      0395            3.6526    224.52           89.73       44.9
78258    Esophageal motility study                        S      0395            3.6526    224.52           89.73       44.9
78261    Gastric mucosa imaging                           S      0395            3.6526    224.52           89.73       44.9
78262    Gastroesophageal reflux exam                     S      0395            3.6526    224.52           89.73       44.9
78264    Gastric emptying study                           S      0395            3.6526    224.52           89.73       44.9
78267    Breath tst attain/anal c-14                      A
78268    Breath test analysis, c-14                       A
78270    Vit B-12 absorption exam                         S      0392            2.0057     123.29             49.31             24.66
78271    Vit b-12 absrp exam, int fac                     S      0392            2.0057     123.29             49.31             24.66
78272    Vit B-12 absorp, combined                        S      0392            2.0057     123.29             49.31             24.66
78278    Acute GI blood loss imaging                      S      0395            3.6526     224.52             89.73              44.9
78282    GI protein loss exam                             S      0395            3.6526     224.52             89.73              44.9
78290    MeckelÆs divert exam                             S      0395            3.6526     224.52             89.73              44.9
78291    Leveen/shunt patency exam                        S      0395            3.6526     224.52             89.73              44.9
78299    GI nuclear procedure                             S      0395            3.6526     224.52             89.73              44.9
78300    Bone imaging, limited area                       S      0396            3.9174     240.79             95.02             48.16
78305    Bone imaging, multiple areas                     S      0396            3.9174     240.79             95.02             48.16
78306    Bone imaging, whole body                         S      0396            3.9174     240.79             95.02             48.16
78315    Bone imaging, 3 phase                            S      0396            3.9174     240.79             95.02             48.16
78320    Bone imaging (3D)                                S      0396            3.9174     240.79             95.02             48.16
78350    Bone mineral, single photon                      X      0260            0.7093       43.6                                8.72
78351    Bone mineral, dual photon                        E
78399    Musculoskeletal nuclear exam                     S      0396       3.9174          240.79             95.02             48.16
78414    Non-imaging heart function                       S      0398       4.1265          253.65            100.06             50.73
78428    Cardiac shunt imaging                            S      0398       4.1265          253.65            100.06             50.73
78445    Vascular flow imaging                            S      0397       2.4204          148.78             49.58             29.76
78456    Acute venous thrombus image                      S      0397       2.4204          148.78             49.58             29.76
78457    Venous thrombosis imaging                        S      0397       2.4204          148.78             49.58             29.76
78458    Ven thrombosis images, bilat                     S        Milliman 2.4204
                                                                 0397                       148.78             49.58             29.76
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                       National   Minimum
HCPCS/                                                                         Relative               Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate    Copayment Copayment
78459    Heart muscle imaging (PET)               CH      S      0307           11.8963    731.24          292.49     146.25
78460    Heart muscle blood, single                       S      0398            4.1265    253.65          100.06      50.73
78461    Heart muscle blood, multiple                     S      0377            6.5012    399.62          158.84      79.92
78464    Heart image (3d), single                         S      0398            4.1265    253.65          100.06      50.73
78465    Heart image (3d), multiple                       S      0377            6.5012    399.62          158.84      79.92
78466    Heart infarct image                              S      0398            4.1265    253.65          100.06      50.73
78468    Heart infarct image (ef)                         S      0398            4.1265    253.65          100.06      50.73
78469    Heart infarct image (3D)                         S      0398            4.1265    253.65          100.06      50.73
78472    Gated heart, planar, single                      S      0398            4.1265    253.65          100.06      50.73
78473    Gated heart, multiple                            S      0376            4.9832    306.31          119.77      61.26
78478    Heart wall motion add-on                         S      0399            1.5054     92.53            35.8      18.51
78480    Heart function add-on                            S      0399            1.5054     92.53            35.8      18.51
78481    Heart first pass, single                         S      0398            4.1265    253.65          100.06      50.73
78483    Heart first pass, multiple                       S      0376            4.9832    306.31          119.77      61.26
78491    Heart image (pet), single                CH      S      0307           11.8963    731.24          292.49     146.25
78492    Heart image (pet), multiple                      S      0307           11.8963    731.24          292.49     146.25
78494    Heart image, spect                               S      0398            4.1265    253.65          100.06      50.73
78496    Heart first pass add-on                          S      0399            1.5054     92.53            35.8      18.51
78499    Cardiovascular nuclear exam                      S      0398            4.1265    253.65          100.06      50.73
78580    Lung perfusion imaging                           S      0401            3.1802    195.48           78.19       39.1
78584    Lung V/Q image single breath                     S      0378            5.0975    313.33          125.33      62.67
78585    Lung V/Q imaging                                 S      0378            5.0975    313.33          125.33      62.67
78586    Aerosol lung image, single                       S      0401            3.1802    195.48           78.19       39.1
78587    Aerosol lung image, multiple                     S      0401            3.1802    195.48           78.19       39.1
78588    Perfusion lung image                             S      0378            5.0975    313.33          125.33      62.67
78591    Vent image, 1 breath, 1 proj                     S      0401            3.1802    195.48           78.19       39.1
78593    Vent image, 1 proj, gas                          S      0401            3.1802    195.48           78.19       39.1
78594    Vent image, mult proj, gas                       S      0401            3.1802    195.48           78.19       39.1
78596    Lung differential function                       S      0378            5.0975    313.33          125.33      62.67
78599    Respiratory nuclear exam                         S      0401            3.1802    195.48           78.19       39.1
78600    Brain imaging, ltd static                        S      0402            4.6418    285.32          114.12      57.06
78601    Brain imaging, ltd w/flow                        S      0402            4.6418    285.32          114.12      57.06
78605    Brain imaging, complete                          S      0402            4.6418    285.32          114.12      57.06
78606    Brain imaging, compl w/flow                      S      0402            4.6418    285.32          114.12      57.06
78607    Brain imaging (3D)                               S      0402            4.6418    285.32          114.12      57.06
78608    Brain imaging (PET)                      CH      S      0308           13.9166    855.43                     171.09
78609    Brain imaging (PET)                              E
78610    Brain flow imaging only                          S      0402            4.6418     285.32            114.12             57.06
78615    Cerebral vascular flow image                     S      0402            4.6418     285.32            114.12             57.06
78630    Cerebrospinal fluid scan                         S      0403            3.4923     214.66             83.35             42.93
78635    CSF ventriculography                             S      0403            3.4923     214.66             83.35             42.93
78645    CSF shunt evaluation                             S      0403            3.4923     214.66             83.35             42.93
78647    Cerebrospinal fluid scan                         S      0403            3.4923     214.66             83.35             42.93
78650    CSF leakage imaging                              S      0403            3.4923     214.66             83.35             42.93
78660    Nuclear exam of tear flow                        S      0403            3.4923     214.66             83.35             42.93
78699    Nervous system nuclear exam                      S      0402            4.6418     285.32            114.12             57.06
78700    Kidney imaging, morphol                          S      0404            3.4209     210.28             84.11             42.06
78701    Kidney imaging with flow                         S      0404            3.4209     210.28             84.11             42.06
78704    Imaging renogram                         CH      D
78707    Kflow/funct image w/o drug                       S      0404       3.4209          210.28             84.11             42.06
78708    Kflow/funct image w/drug                         S      0405       4.0378           248.2             98.77             49.64
78709    Kflow/funct image, multiple                      S      0405       4.0378           248.2             98.77             49.64
78710    Kidney imaging (3D)                              S        Milliman 3.4209
                                                                 0404                       210.28             84.11             42.06
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
78715    Renal vascular flow exam                 CH      D
78725    Kidney function study                            S      0389            1.3754         84.54            33.81             16.91
78730    Urinary bladder retention                        X      0340            0.6102         37.51                                7.5
78740    Ureteral reflux study                            S      0404            3.4209        210.28            84.11             42.06
78760    Testicular imaging                       CH      D
78761    Testicular imaging w/flow                        S      0404            3.4209        210.28            84.11          42.06
78799    Genitourinary nuclear exam                       S      0404            3.4209        210.28            84.11          42.06
78800    Tumor imaging, limited area                      S      0406            3.9934        245.47            98.18          49.09
78801    Tumor imaging, mult areas                        S      0406            3.9934        245.47            98.18          49.09
78802    Tumor imaging, whole body                        S      0406            3.9934        245.47            98.18          49.09
78803    Tumor imaging (3D)                               S      0406            3.9934        245.47            98.18          49.09
78804    Tumor imaging, whole body                CH      S      0408            5.9245        364.17                           72.83
78805    Abscess imaging, ltd area                        S      0406            3.9934        245.47            98.18          49.09
78806    Abscess imaging, whole body                      S      0406            3.9934        245.47            98.18          49.09
78807    Nuclear localization/abscess                     S      0406            3.9934        245.47            98.18          49.09
78811    Tumor imaging (pet), limited             CH      S      0308           13.9166        855.43                          171.09
78812    Tumor image (pet)/skul-thigh             CH      S      0308           13.9166        855.43                          171.09
78813    Tumor image (pet) full body              CH      S      0308           13.9166        855.43                          171.09
78814    Tumor image pet/ct, limited              CH      S      1511                             950                             190
78815    Tumorimage pet/ct skul-thigh             CH      S      1511                             950                             190
78816    Tumor image pet/ct full body             CH      S      1511                             950                             190
78890    Nuclear medicine data proc                       N
78891    Nuclear med data proc                            N
78999    Nuclear diagnostic exam                          S      0389            1.3754         84.54            33.81             16.91
79005    Nuclear rx, oral admin                           S      0407            3.1779        195.34            78.13             39.07
79101    Nuclear rx, iv admin                             S      0407            3.1779        195.34            78.13             39.07
79200    Nuclear rx, intracav admin               CH      S      0413            5.2957        325.52                               65.1
79300    Nuclr rx, interstit colloid                      S      0407            3.1779        195.34            78.13             39.07
79403    Hematopoietic nuclear tx                 CH      S      0413            5.2957        325.52                               65.1
79440    Nuclear rx, intra-articular              CH      S      0413            5.2957        325.52                               65.1
79445    Nuclear rx, intra-arterial                       S      0407            3.1779        195.34            78.13             39.07
79999    Nuclear medicine therapy                         S      0407            3.1779        195.34            78.13             39.07
80048    Basic metabolic panel                            A
80050    General health panel                             E
80051    Electrolyte panel                                A
80053    Comprehen metabolic panel                        A
80055    Obstetric panel                                  E
80061    Lipid panel                                      A
80069    Renal function panel                             A
80074    Acute hepatitis panel                            A
80076    Hepatic function panel                           A
80100    Drug screen, qualitate/multi                     A
80101    Drug screen, single                              A
80102    Drug confirmation                                A
80103    Drug analysis, tissue prep                       N
80150    Assay of amikacin                                A
80152    Assay of amitriptyline                           A
80154    Assay of benzodiazepines                         A
80156    Assay, carbamazepine, total                      A
80157    Assay, carbamazepine, free                       A
80158    Assay of cyclosporine                            A
80160    Assay of desipramine                             A
80162    Assay of digoxin                                 A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National         Minimum
HCPCS/                                                                         Relative                Unadjusted        Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment         Copayment
80164    Assay, dipropylacetic acid                       A
80166    Assay of doxepin                                 A
80168    Assay of ethosuximide                            A
80170    Assay of gentamicin                              A
80172    Assay of gold                                    A
80173    Assay of haloperidol                             A
80174    Assay of imipramine                              A
80176    Assay of lidocaine                               A
80178    Assay of lithium                                 A
80182    Assay of nortriptyline                           A
80184    Assay of phenobarbital                           A
80185    Assay of phenytoin, total                        A
80186    Assay of phenytoin, free                         A
80188    Assay of primidone                               A
80190    Assay of procainamide                            A
80192    Assay of procainamide                            A
80194    Assay of quinidine                               A
80195    Assay of sirolimus                               A
80196    Assay of salicylate                              A
80197    Assay of tacrolimus                              A
80198    Assay of theophylline                            A
80200    Assay of tobramycin                              A
80201    Assay of topiramate                              A
80202    Assay of vancomycin                              A
80299    Quantitative assay, drug                         A
80400    Acth stimulation panel                           A
80402    Acth stimulation panel                           A
80406    Acth stimulation panel                           A
80408    Aldosterone suppression eval                     A
80410    Calcitonin stimul panel                          A
80412    CRH stimulation panel                            A
80414    Testosterone response                            A
80415    Estradiol response panel                         A
80416    Renin stimulation panel                          A
80417    Renin stimulation panel                          A
80418    Pituitary evaluation panel                       A
80420    Dexamethasone panel                              A
80422    Glucagon tolerance panel                         A
80424    Glucagon tolerance panel                         A
80426    Gonadotropin hormone panel                       A
80428    Growth hormone panel                             A
80430    Growth hormone panel                             A
80432    Insulin suppression panel                        A
80434    Insulin tolerance panel                          A
80435    Insulin tolerance panel                          A
80436    Metyrapone panel                                 A
80438    TRH stimulation panel                            A
80439    TRH stimulation panel                            A
80440    TRH stimulation panel                            A
80500    Lab pathology consultation                       X      0433            0.2557         15.72            5.93             3.14
80502    Lab pathology consultation                       X      0342            0.0824          5.06            2.02             1.01
81000    Urinalysis, nonauto w/scope                      A
81001    Urinalysis, auto w/scope                         A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National         Minimum
HCPCS/                                                                         Relative                Unadjusted        Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment         Copayment
81002    Urinalysis nonauto w/o scope                     A
81003    Urinalysis, auto, w/o scope                      A
81005    Urinalysis                                       A
81007    Urine screen for bacteria                        A
81015    Microscopic exam of urine                        A
81020    Urinalysis, glass test                           A
81025    Urine pregnancy test                             A
81050    Urinalysis, volume measure                       A
81099    Urinalysis test procedure                        X      0342            0.0824          5.06            2.02             1.01
82000    Assay of blood acetaldehyde                      A
82003    Assay of acetaminophen                           A
82009    Test for acetone/ketones                         A
82010    Acetone assay                                    A
82013    Acetylcholinesterase assay                       A
82016    Acylcarnitines, qual                             A
82017    Acylcarnitines, quant                            A
82024    Assay of acth                                    A
82030    Assay of adp & amp                               A
82040    Assay of serum albumin                           A
82042    Assay of urine albumin                           A
82043    Microalbumin, quantitative                       A
82044    Microalbumin, semiquant                          A
82045    Albumin, ischemia modified                       A
82055    Assay of ethanol                                 A
82075    Assay of breath ethanol                          A
82085    Assay of aldolase                                A
82088    Assay of aldosterone                             A
82101    Assay of urine alkaloids                         A
82103    Alpha-1-antitrypsin, total                       A
82104    Alpha-1-antitrypsin, pheno                       A
82105    Alpha-fetoprotein, serum                         A
82106    Alpha-fetoprotein, amniotic                      A
82107    Alpha-fetoprotein l3                     NI      A
82108    Assay of aluminum                                A
82120    Amines, vaginal fluid qual                       A
82127    Amino acid, single qual                          A
82128    Amino acids, mult qual                           A
82131    Amino acids, single quant                        A
82135    Assay, aminolevulinic acid                       A
82136    Amino acids, quant, 2-5                          A
82139    Amino acids, quan, 6 or more                     A
82140    Assay of ammonia                                 A
82143    Amniotic fluid scan                              A
82145    Assay of amphetamines                            A
82150    Assay of amylase                                 A
82154    Androstanediol glucuronide                       A
82157    Assay of androstenedione                         A
82160    Assay of androsterone                            A
82163    Assay of angiotensin II                          A
82164    Angiotensin I enzyme test                        A
82172    Assay of apolipoprotein                          A
82175    Assay of arsenic                                 A
82180    Assay of ascorbic acid                           A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
82190    Atomic absorption                                A
82205    Assay of barbiturates                            A
82232    Assay of beta-2 protein                          A
82239    Bile acids, total                                A
82240    Bile acids, cholylglycine                        A
82247    Bilirubin, total                                 A
82248    Bilirubin, direct                                A
82252    Fecal bilirubin test                             A
82261    Assay of biotinidase                             A
82270    Occult blood, feces                              A
82271    Occult blood, other sources                      A
82272    Occult blood, feces, single                      A
82274    Assay test for blood, fecal                      A
82286    Assay of bradykinin                              A
82300    Assay of cadmium                                 A
82306    Assay of vitamin D                               A
82307    Assay of vitamin D                               A
82308    Assay of calcitonin                              A
82310    Assay of calcium                                 A
82330    Assay of calcium                                 A
82331    Calcium infusion test                            A
82340    Assay of calcium in urine                        A
82355    Calculus analysis, qual                          A
82360    Calculus assay, quant                            A
82365    Calculus spectroscopy                            A
82370    X-ray assay, calculus                            A
82373    Assay, c-d transfer measure                      A
82374    Assay, blood carbon dioxide                      A
82375    Assay, blood carbon monoxide                     A
82376    Test for carbon monoxide                         A
82378    Carcinoembryonic antigen                         A
82379    Assay of carnitine                               A
82380    Assay of carotene                                A
82382    Assay, urine catecholamines                      A
82383    Assay, blood catecholamines                      A
82384    Assay, three catecholamines                      A
82387    Assay of cathepsin-d                             A
82390    Assay of ceruloplasmin                           A
82397    Chemiluminescent assay                           A
82415    Assay of chloramphenicol                         A
82435    Assay of blood chloride                          A
82436    Assay of urine chloride                          A
82438    Assay, other fluid chlorides                     A
82441    Test for chlorohydrocarbons                      A
82465    Assay, bld/serum cholesterol                     A
82480    Assay, serum cholinesterase                      A
82482    Assay, rbc cholinesterase                        A
82485    Assay, chondroitin sulfate                       A
82486    Gas/liquid chromatography                        A
82487    Paper chromatography                             A
82488    Paper chromatography                             A
82489    Thin layer chromatography                        A
82491    Chromotography, quant, sing                      A        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 109 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
82492    Chromotography, quant, mult                      A
82495    Assay of chromium                                A
82507    Assay of citrate                                 A
82520    Assay of cocaine                                 A
82523    Collagen crosslinks                              A
82525    Assay of copper                                  A
82528    Assay of corticosterone                          A
82530    Cortisol, free                                   A
82533    Total cortisol                                   A
82540    Assay of creatine                                A
82541    Column chromotography, qual                      A
82542    Column chromotography, quant                     A
82543    Column chromotograph/isotope                     A
82544    Column chromotograph/isotope                     A
82550    Assay of ck (cpk)                                A
82552    Assay of cpk in blood                            A
82553    Creatine, MB fraction                            A
82554    Creatine, isoforms                               A
82565    Assay of creatinine                              A
82570    Assay of urine creatinine                        A
82575    Creatinine clearance test                        A
82585    Assay of cryofibrinogen                          A
82595    Assay of cryoglobulin                            A
82600    Assay of cyanide                                 A
82607    Vitamin B-12                                     A
82608    B-12 binding capacity                            A
82615    Test for urine cystines                          A
82626    Dehydroepiandrosterone                           A
82627    Dehydroepiandrosterone                           A
82633    Desoxycorticosterone                             A
82634    Deoxycortisol                                    A
82638    Assay of dibucaine number                        A
82646    Assay of dihydrocodeinone                        A
82649    Assay of dihydromorphinone                       A
82651    Assay of dihydrotestosterone                     A
82652    Assay of dihydroxyvitamin d                      A
82654    Assay of dimethadione                            A
82656    Pancreatic elastase, fecal                       A
82657    Enzyme cell activity                             A
82658    Enzyme cell activity, ra                         A
82664    Electrophoretic test                             A
82666    Assay of epiandrosterone                         A
82668    Assay of erythropoietin                          A
82670    Assay of estradiol                               A
82671    Assay of estrogens                               A
82672    Assay of estrogen                                A
82677    Assay of estriol                                 A
82679    Assay of estrone                                 A
82690    Assay of ethchlorvynol                           A
82693    Assay of ethylene glycol                         A
82696    Assay of etiocholanolone                         A
82705    Fats/lipids, feces, qual                         A
82710    Fats/lipids, feces, quant                        A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
82715    Assay of fecal fat                               A
82725    Assay of blood fatty acids                       A
82726    Long chain fatty acids                           A
82728    Assay of ferritin                                A
82731    Assay of fetal fibronectin                       A
82735    Assay of fluoride                                A
82742    Assay of flurazepam                              A
82746    Blood folic acid serum                           A
82747    Assay of folic acid, rbc                         A
82757    Assay of semen fructose                          A
82759    Assay of rbc galactokinase                       A
82760    Assay of galactose                               A
82775    Assay galactose transferase                      A
82776    Galactose transferase test                       A
82784    Assay of gammaglobulin igm                       A
82785    Assay of gammaglobulin ige                       A
82787    Igg 1, 2, 3 or 4, each                           A
82800    Blood pH                                         A
82803    Blood gases: pH, pO2 & pCO2                      A
82805    Blood gases W/02 saturation                      A
82810    Blood gases, O2 sat only                         A
82820    Hemoglobin-oxygen affinity                       A
82926    Assay of gastric acid                            A
82928    Assay of gastric acid                            A
82938    Gastrin test                                     A
82941    Assay of gastrin                                 A
82943    Assay of glucagon                                A
82945    Glucose other fluid                              A
82946    Glucagon tolerance test                          A
82947    Assay, glucose, blood quant                      A
82948    Reagent strip/blood glucose                      A
82950    Glucose test                                     A
82951    Glucose tolerance test (GTT)                     A
82952    GTT-added samples                                A
82953    Glucose-tolbutamide test                         A
82955    Assay of g6pd enzyme                             A
82960    Test for G6PD enzyme                             A
82962    Glucose blood test                               A
82963    Assay of glucosidase                             A
82965    Assay of gdh enzyme                              A
82975    Assay of glutamine                               A
82977    Assay of GGT                                     A
82978    Assay of glutathione                             A
82979    Assay, rbc glutathione                           A
82980    Assay of glutethimide                            A
82985    Glycated protein                                 A
83001    Gonadotropin (FSH)                               A
83002    Gonadotropin (LH)                                A
83003    Assay, growth hormone (hgh)                      A
83008    Assay of guanosine                               A
83009    H pylori (c-13), blood                           A
83010    Assay of haptoglobin, quant                      A
83012    Assay of haptoglobins                            A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
83013    H pylori (c-13), breath                          A
83014    H pylori drug admin                              A
83015    Heavy metal screen                               A
83018    Quantitative screen, metals                      A
83020    Hemoglobin electrophoresis                       A
83021    Hemoglobin chromotography                        A
83026    Hemoglobin, copper sulfate                       A
83030    Fetal hemoglobin, chemical                       A
83033    Fetal hemoglobin assay, qual                     A
83036    Glycosylated hemoglobin test                     A
83037    Glycosylated hb, home device                     A
83045    Blood methemoglobin test                         A
83050    Blood methemoglobin assay                        A
83051    Assay of plasma hemoglobin                       A
83055    Blood sulfhemoglobin test                        A
83060    Blood sulfhemoglobin assay                       A
83065    Assay of hemoglobin heat                         A
83068    Hemoglobin stability screen                      A
83069    Assay of urine hemoglobin                        A
83070    Assay of hemosiderin, qual                       A
83071    Assay of hemosiderin, quant                      A
83080    Assay of b hexosaminidase                        A
83088    Assay of histamine                               A
83090    Assay of homocystine                             A
83150    Assay of for hva                                 A
83491    Assay of corticosteroids                         A
83497    Assay of 5-hiaa                                  A
83498    Assay of progesterone                            A
83499    Assay of progesterone                            A
83500    Assay, free hydroxyproline                       A
83505    Assay, total hydroxyproline                      A
83516    Immunoassay, nonantibody                         A
83518    Immunoassay, dipstick                            A
83519    Immunoassay, nonantibody                         A
83520    Immunoassay, RIA                                 A
83525    Assay of insulin                                 A
83527    Assay of insulin                                 A
83528    Assay of intrinsic factor                        A
83540    Assay of iron                                    A
83550    Iron binding test                                A
83570    Assay of idh enzyme                              A
83582    Assay of ketogenic steroids                      A
83586    Assay 17- ketosteroids                           A
83593    Fractionation, ketosteroids                      A
83605    Assay of lactic acid                             A
83615    Lactate (LD) (LDH) enzyme                        A
83625    Assay of ldh enzymes                             A
83630    Lactoferrin, fecal (qual)                        A
83631    Lactoferrin, fecal (quant)                       A
83632    Placental lactogen                               A
83633    Test urine for lactose                           A
83634    Assay of urine for lactose                       A
83655    Assay of lead                                    A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
83661    L/s ratio, fetal lung                            A
83662    Foam stability, fetal lung                       A
83663    Fluoro polarize, fetal lung                      A
83664    Lamellar bdy, fetal lung                         A
83670    Assay of lap enzyme                              A
83690    Assay of lipase                                  A
83695    Assay of lipoprotein(a)                          A
83698    Assay lipoprotein pla2                   NI      A
83700    Lipopro bld, electrophoretic                     A
83701    Lipoprotein bld, hr fraction                     A
83704    Lipoprotein, bld, by nmr                         A
83718    Assay of lipoprotein                             A
83719    Assay of blood lipoprotein                       A
83721    Assay of blood lipoprotein                       A
83727    Assay of lrh hormone                             A
83735    Assay of magnesium                               A
83775    Assay of md enzyme                               A
83785    Assay of manganese                               A
83788    Mass spectrometry qual                           A
83789    Mass spectrometry quant                          A
83805    Assay of meprobamate                             A
83825    Assay of mercury                                 A
83835    Assay of metanephrines                           A
83840    Assay of methadone                               A
83857    Assay of methemalbumin                           A
83858    Assay of methsuximide                            A
83864    Mucopolysaccharides                              A
83866    Mucopolysaccharides screen                       A
83872    Assay synovial fluid mucin                       A
83873    Assay of csf protein                             A
83874    Assay of myoglobin                               A
83880    Natriuretic peptide                              A
83883    Assay, nephelometry not spec                     A
83885    Assay of nickel                                  A
83887    Assay of nicotine                                A
83890    Molecule isolate                                 A
83891    Molecule isolate nucleic                         A
83892    Molecular diagnostics                            A
83893    Molecule dot/slot/blot                           A
83894    Molecule gel electrophor                         A
83896    Molecular diagnostics                            A
83897    Molecule nucleic transfer                        A
83898    Molecule nucleic ampli, each                     A
83900    Molecule nucleic ampli 2 seq                     A
83901    Molecule nucleic ampli addon                     A
83902    Molecular diagnostics                            A
83903    Molecule mutation scan                           A
83904    Molecule mutation identify                       A
83905    Molecule mutation identify                       A
83906    Molecule mutation identify                       A
83907    Lyse cells for nucleic ext                       A
83908    Nucleic acid, signal ampli                       A
83909    Nucleic acid, high resolute                      A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 113 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
83912    Genetic examination                              A
83913    Molecular, rna stabilization             NI      A
83914    Mutation ident ola/sbce/aspe                     A
83915    Assay of nucleotidase                            A
83916    Oligoclonal bands                                A
83918    Organic acids, total, quant                      A
83919    Organic acids, qual, each                        A
83921    Organic acid, single, quant                      A
83925    Assay of opiates                                 A
83930    Assay of blood osmolality                        A
83935    Assay of urine osmolality                        A
83937    Assay of osteocalcin                             A
83945    Assay of oxalate                                 A
83950    Oncoprotein, her-2/neu                           A
83970    Assay of parathormone                            A
83986    Assay of body fluid acidity                      A
83992    Assay for phencyclidine                          A
84022    Assay of phenothiazine                           A
84030    Assay of blood pku                               A
84035    Assay of phenylketones                           A
84060    Assay acid phosphatase                           A
84061    Phosphatase, forensic exam                       A
84066    Assay prostate phosphatase                       A
84075    Assay alkaline phosphatase                       A
84078    Assay alkaline phosphatase                       A
84080    Assay alkaline phosphatases                      A
84081    Amniotic fluid enzyme test                       A
84085    Assay of rbc pg6d enzyme                         A
84087    Assay phosphohexose enzymes                      A
84100    Assay of phosphorus                              A
84105    Assay of urine phosphorus                        A
84106    Test for porphobilinogen                         A
84110    Assay of porphobilinogen                         A
84119    Test urine for porphyrins                        A
84120    Assay of urine porphyrins                        A
84126    Assay of feces porphyrins                        A
84127    Assay of feces porphyrins                        A
84132    Assay of serum potassium                         A
84133    Assay of urine potassium                         A
84134    Assay of prealbumin                              A
84135    Assay of pregnanediol                            A
84138    Assay of pregnanetriol                           A
84140    Assay of pregnenolone                            A
84143    Assay of 17-hydroxypregneno                      A
84144    Assay of progesterone                            A
84146    Assay of prolactin                               A
84150    Assay of prostaglandin                           A
84152    Assay of psa, complexed                          A
84153    Assay of psa, total                              A
84154    Assay of psa, free                               A
84155    Assay of protein, serum                          A
84156    Assay of protein, urine                          A
84157    Assay of protein, other                          A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
84160    Assay of protein, any source                     A
84163    Pappa, serum                                     A
84165    Protein e-phoresis, serum                        A
84166    Protein e-phoresis/urine/csf                     A
84181    Western blot test                                A
84182    Protein, western blot test                       A
84202    Assay RBC protoporphyrin                         A
84203    Test RBC protoporphyrin                          A
84206    Assay of proinsulin                              A
84207    Assay of vitamin b-6                             A
84210    Assay of pyruvate                                A
84220    Assay of pyruvate kinase                         A
84228    Assay of quinine                                 A
84233    Assay of estrogen                                A
84234    Assay of progesterone                            A
84235    Assay of endocrine hormone                       A
84238    Assay, nonendocrine receptor                     A
84244    Assay of renin                                   A
84252    Assay of vitamin b-2                             A
84255    Assay of selenium                                A
84260    Assay of serotonin                               A
84270    Assay of sex hormone globul                      A
84275    Assay of sialic acid                             A
84285    Assay of silica                                  A
84295    Assay of serum sodium                            A
84300    Assay of urine sodium                            A
84302    Assay of sweat sodium                            A
84305    Assay of somatomedin                             A
84307    Assay of somatostatin                            A
84311    Spectrophotometry                                A
84315    Body fluid specific gravity                      A
84375    Chromatogram assay, sugars                       A
84376    Sugars, single, qual                             A
84377    Sugars, multiple, qual                           A
84378    Sugars, single, quant                            A
84379    Sugars multiple quant                            A
84392    Assay of urine sulfate                           A
84402    Assay of testosterone                            A
84403    Assay of total testosterone                      A
84425    Assay of vitamin b-1                             A
84430    Assay of thiocyanate                             A
84432    Assay of thyroglobulin                           A
84436    Assay of total thyroxine                         A
84437    Assay of neonatal thyroxine                      A
84439    Assay of free thyroxine                          A
84442    Assay of thyroid activity                        A
84443    Assay thyroid stim hormone                       A
84445    Assay of tsi                                     A
84446    Assay of vitamin e                               A
84449    Assay of transcortin                             A
84450    Transferase (AST) (SGOT)                         A
84460    Alanine amino (ALT) (SGPT)                       A
84466    Assay of transferrin                             A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National         Minimum
HCPCS/                                                                         Relative                Unadjusted        Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment         Copayment
84478    Assay of triglycerides                           A
84479    Assay of thyroid (t3 or t4)                      A
84480    Assay, triiodothyronine (t3)                     A
84481    Free assay (FT-3)                                A
84482    T3 reverse                                       A
84484    Assay of troponin, quant                         A
84485    Assay duodenal fluid trypsin                     A
84488    Test feces for trypsin                           A
84490    Assay of feces for trypsin                       A
84510    Assay of tyrosine                                A
84512    Assay of troponin, qual                          A
84520    Assay of urea nitrogen                           A
84525    Urea nitrogen semi-quant                         A
84540    Assay of urine/urea-n                            A
84545    Urea-N clearance test                            A
84550    Assay of blood/uric acid                         A
84560    Assay of urine/uric acid                         A
84577    Assay of feces/urobilinogen                      A
84578    Test urine urobilinogen                          A
84580    Assay of urine urobilinogen                      A
84583    Assay of urine urobilinogen                      A
84585    Assay of urine vma                               A
84586    Assay of vip                                     A
84588    Assay of vasopressin                             A
84590    Assay of vitamin a                               A
84591    Assay of nos vitamin                             A
84597    Assay of vitamin k                               A
84600    Assay of volatiles                               A
84620    Xylose tolerance test                            A
84630    Assay of zinc                                    A
84681    Assay of c-peptide                               A
84702    Chorionic gonadotropin test                      A
84703    Chorionic gonadotropin assay                     A
84830    Ovulation tests                                  A
84999    Clinical chemistry test                          X      0342            0.0824          5.06            2.02             1.01
85002    Bleeding time test                               A
85004    Automated diff wbc count                         A
85007    Bl smear w/diff wbc count                        A
85008    Bl smear w/o diff wbc count                      A
85009    Manual diff wbc count b-coat                     A
85013    Spun microhematocrit                             A
85014    Hematocrit                                       A
85018    Hemoglobin                                       A
85025    Complete cbc w/auto diff wbc                     A
85027    Complete cbc, automated                          A
85032    Manual cell count, each                          A
85041    Automated rbc count                              A
85044    Manual reticulocyte count                        A
85045    Automated reticulocyte count                     A
85046    Reticyte/hgb concentrate                         A
85048    Automated leukocyte count                        A
85049    Automated platelet count                         A
85055    Reticulated platelet assay                       A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
85060    Blood smear interpretation                       B
85097    Bone marrow interpretation                       X      0343            0.5211         32.03            10.84             6.41
85130    Chromogenic substrate assay                      A
85170    Blood clot retraction                            A
85175    Blood clot lysis time                            A
85210    Blood clot factor II test                        A
85220    Blood clot factor V test                         A
85230    Blood clot factor VII test                       A
85240    Blood clot factor VIII test                      A
85244    Blood clot factor VIII test                      A
85245    Blood clot factor VIII test                      A
85246    Blood clot factor VIII test                      A
85247    Blood clot factor VIII test                      A
85250    Blood clot factor IX test                        A
85260    Blood clot factor X test                         A
85270    Blood clot factor XI test                        A
85280    Blood clot factor XII test                       A
85290    Blood clot factor XIII test                      A
85291    Blood clot factor XIII test                      A
85292    Blood clot factor assay                          A
85293    Blood clot factor assay                          A
85300    Antithrombin III test                            A
85301    Antithrombin III test                            A
85302    Blood clot inhibitor antigen                     A
85303    Blood clot inhibitor test                        A
85305    Blood clot inhibitor assay                       A
85306    Blood clot inhibitor test                        A
85307    Assay activated protein c                        A
85335    Factor inhibitor test                            A
85337    Thrombomodulin                                   A
85345    Coagulation time                                 A
85347    Coagulation time                                 A
85348    Coagulation time                                 A
85360    Euglobulin lysis                                 A
85362    Fibrin degradation products                      A
85366    Fibrinogen test                                  A
85370    Fibrinogen test                                  A
85378    Fibrin degrade, semiquant                        A
85379    Fibrin degradation, quant                        A
85380    Fibrin degradation, vte                          A
85384    Fibrinogen                                       A
85385    Fibrinogen                                       A
85390    Fibrinolysins screen                             A
85396    Clotting assay, whole blood                      N
85400    Fibrinolytic plasmin                             A
85410    Fibrinolytic antiplasmin                         A
85415    Fibrinolytic plasminogen                         A
85420    Fibrinolytic plasminogen                         A
85421    Fibrinolytic plasminogen                         A
85441    Heinz bodies, direct                             A
85445    Heinz bodies, induced                            A
85460    Hemoglobin, fetal                                A
85461    Hemoglobin, fetal                                A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
85475    Hemolysin                                        A
85520    Heparin assay                                    A
85525    Heparin neutralization                           A
85530    Heparin-protamine tolerance                      A
85536    Iron stain peripheral blood                      A
85540    Wbc alkaline phosphatase                         A
85547    RBC mechanical fragility                         A
85549    Muramidase                                       A
85555    RBC osmotic fragility                            A
85557    RBC osmotic fragility                            A
85576    Blood platelet aggregation                       A
85597    Platelet neutralization                          A
85610    Prothrombin time                                 A
85611    Prothrombin test                                 A
85612    Viper venom prothrombin time                     A
85613    Russell viper venom, diluted                     A
85635    Reptilase test                                   A
85651    Rbc sed rate, nonautomated                       A
85652    Rbc sed rate, automated                          A
85660    RBC sickle cell test                             A
85670    Thrombin time, plasma                            A
85675    Thrombin time, titer                             A
85705    Thromboplastin inhibition                        A
85730    Thromboplastin time, partial                     A
85732    Thromboplastin time, partial                     A
85810    Blood viscosity examination                      A
85999    Hematology procedure                             X      0342            0.0824          5.06             2.02             1.01
86000    Agglutinins, febrile                             A
86001    Allergen specific igg                            A
86003    Allergen specific IgE                            A
86005    Allergen specific IgE                            A
86021    WBC antibody identification                      A
86022    Platelet antibodies                              A
86023    Immunoglobulin assay                             A
86038    Antinuclear antibodies                           A
86039    Antinuclear antibodies (ANA)                     A
86060    Antistreptolysin o, titer                        A
86063    Antistreptolysin o, screen                       A
86077    Physician blood bank service                     X      0433            0.2557         15.72             5.93             3.14
86078    Physician blood bank service                     X      0343            0.5211         32.03            10.84             6.41
86079    Physician blood bank service                     X      0433            0.2557         15.72             5.93             3.14
86140    C-reactive protein                               A
86141    C-reactive protein, hs                           A
86146    Glycoprotein antibody                            A
86147    Cardiolipin antibody                             A
86148    Phospholipid antibody                            A
86155    Chemotaxis assay                                 A
86156    Cold agglutinin, screen                          A
86157    Cold agglutinin, titer                           A
86160    Complement, antigen                              A
86161    Complement/function activity                     A
86162    Complement, total (CH50)                         A
86171    Complement fixation, each                        A        Milliman
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                   Page 118 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National         Minimum
HCPCS/                                                                         Relative                Unadjusted        Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment         Copayment
86185    Counterimmunoelectrophoresis                     A
86200    Ccp antibody                                     A
86215    Deoxyribonuclease, antibody                      A
86225    DNA antibody                                     A
86226    DNA antibody, single strand                      A
86235    Nuclear antigen antibody                         A
86243    Fc receptor                                      A
86255    Fluorescent antibody, screen                     A
86256    Fluorescent antibody, titer                      A
86277    Growth hormone antibody                          A
86280    Hemagglutination inhibition                      A
86294    Immunoassay, tumor, qual                         A
86300    Immunoassay, tumor, ca 15-3                      A
86301    Immunoassay, tumor, ca 19-9                      A
86304    Immunoassay, tumor, ca 125                       A
86308    Heterophile antibodies                           A
86309    Heterophile antibodies                           A
86310    Heterophile antibodies                           A
86316    Immunoassay, tumor other                         A
86317    Immunoassay,infectious agent                     A
86318    Immunoassay,infectious agent                     A
86320    Serum immunoelectrophoresis                      A
86325    Other immunoelectrophoresis                      A
86327    Immunoelectrophoresis assay                      A
86329    Immunodiffusion                                  A
86331    Immunodiffusion ouchterlony                      A
86332    Immune complex assay                             A
86334    Immunofix e-phoresis, serum                      A
86335    Immunfix e-phorsis/urine/csf                     A
86336    Inhibin A                                        A
86337    Insulin antibodies                               A
86340    Intrinsic factor antibody                        A
86341    Islet cell antibody                              A
86343    Leukocyte histamine release                      A
86344    Leukocyte phagocytosis                           A
86353    Lymphocyte transformation                        A
86355    B cells, total count                             A
86357    Nk cells, total count                            A
86359    T cells, total count                             A
86360    T cell, absolute count/ratio                     A
86361    T cell, absolute count                           A
86367    Stem cells, total count                          A
86376    Microsomal antibody                              A
86378    Migration inhibitory factor                      A
86382    Neutralization test, viral                       A
86384    Nitroblue tetrazolium dye                        A
86403    Particle agglutination test                      A
86406    Particle agglutination test                      A
86430    Rheumatoid factor test                           A
86431    Rheumatoid factor, quant                         A
86480    Tb test, cell immun measure                      A
86485    Skin test, candida                               X      0341       0.0914               5.62            2.24             1.12
86490    Coccidioidomycosis skin test                     X        Milliman 0.0914
                                                                 0341                            5.62            2.24             1.12
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                  Page 119 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                  61.468      2007 CF
                                                                                                    National   Minimum
HCPCS/                                                                         Relative            Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment Copayment
86510    Histoplasmosis skin test                         X      0341            0.0914       5.62        2.24       1.12
86580    TB intradermal test                              X      0341            0.0914       5.62        2.24       1.12
86586    Skin test, unlisted                              A
86590    Streptokinase, antibody                          A
86592    Blood serology, qualitative                      A
86593    Blood serology, quantitative                     A
86602    Antinomyces antibody                             A
86603    Adenovirus antibody                              A
86606    Aspergillus antibody                             A
86609    Bacterium antibody                               A
86611    Bartonella antibody                              A
86612    Blastomyces antibody                             A
86615    Bordetella antibody                              A
86617    Lyme disease antibody                            A
86618    Lyme disease antibody                            A
86619    Borrelia antibody                                A
86622    Brucella antibody                                A
86625    Campylobacter antibody                           A
86628    Candida antibody                                 A
86631    Chlamydia antibody                               A
86632    Chlamydia igm antibody                           A
86635    Coccidioides antibody                            A
86638    Q fever antibody                                 A
86641    Cryptococcus antibody                            A
86644    CMV antibody                                     A
86645    CMV antibody, IgM                                A
86648    Diphtheria antibody                              A
86651    Encephalitis antibody                            A
86652    Encephalitis antibody                            A
86653    Encephalitis antibody                            A
86654    Encephalitis antibody                            A
86658    Enterovirus antibody                             A
86663    Epstein-barr antibody                            A
86664    Epstein-barr antibody                            A
86665    Epstein-barr antibody                            A
86666    Ehrlichia antibody                               A
86668    Francisella tularensis                           A
86671    Fungus antibody                                  A
86674    Giardia lamblia antibody                         A
86677    Helicobacter pylori                              A
86682    Helminth antibody                                A
86684    Hemophilus influenza                             A
86687    Htlv-i antibody                                  A
86688    Htlv-ii antibody                                 A
86689    HTLV/HIV confirmatory test                       A
86692    Hepatitis, delta agent                           A
86694    Herpes simplex test                              A
86695    Herpes simplex test                              A
86696    Herpes simplex type 2                            A
86698    Histoplasma                                      A
86701    HIV-1                                            A
86702    HIV-2                                            A
86703    HIV-1/HIV-2, single assay                        A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                        Page 120 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
86704    Hep b core antibody, total                       A
86705    Hep b core antibody, igm                         A
86706    Hep b surface antibody                           A
86707    Hep be antibody                                  A
86708    Hep a antibody, total                            A
86709    Hep a antibody, igm                              A
86710    Influenza virus antibody                         A
86713    Legionella antibody                              A
86717    Leishmania antibody                              A
86720    Leptospira antibody                              A
86723    Listeria monocytogenes ab                        A
86727    Lymph choriomeningitis ab                        A
86729    Lympho venereum antibody                         A
86732    Mucormycosis antibody                            A
86735    Mumps antibody                                   A
86738    Mycoplasma antibody                              A
86741    Neisseria meningitidis                           A
86744    Nocardia antibody                                A
86747    Parvovirus antibody                              A
86750    Malaria antibody                                 A
86753    Protozoa antibody nos                            A
86756    Respiratory virus antibody                       A
86757    Rickettsia antibody                              A
86759    Rotavirus antibody                               A
86762    Rubella antibody                                 A
86765    Rubeola antibody                                 A
86768    Salmonella antibody                              A
86771    Shigella antibody                                A
86774    Tetanus antibody                                 A
86777    Toxoplasma antibody                              A
86778    Toxoplasma antibody, igm                         A
86781    Treponema pallidum, confirm                      A
86784    Trichinella antibody                             A
86787    Varicella-zoster antibody                        A
86788    West nile virus ab, igm                  NI      A
86789    West nile virus antibody                 NI      A
86790    Virus antibody nos                               A
86793    Yersinia antibody                                A
86800    Thyroglobulin antibody                           A
86803    Hepatitis c ab test                              A
86804    Hep c ab test, confirm                           A
86805    Lymphocytotoxicity assay                         A
86806    Lymphocytotoxicity assay                         A
86807    Cytotoxic antibody screening                     A
86808    Cytotoxic antibody screening                     A
86812    HLA typing, A, B, or C                           A
86813    HLA typing, A, B, or C                           A
86816    HLA typing, DR/DQ                                A
86817    HLA typing, DR/DQ                                A
86821    Lymphocyte culture, mixed                        A
86822    Lymphocyte culture, primed                       A
86849    Immunology procedure                             X      0342       0.0824              $5.06            $2.02             $1.01
86850    RBC antibody screen                              X        Milliman 0.2178
                                                                 0345                          $13.39            $2.87             $2.68
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                   Page 121 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate     Copayment Copayment
86860    RBC antibody elution                             X      0346            0.3484   $21.42            $4.39      $4.28
86870    RBC antibody identification                      X      0346            0.3484   $21.42            $4.39      $4.28
86880    Coombs test, direct                              X      0409            0.1227    $7.54            $2.20      $1.51
86885    Coombs test, indirect, qual                      X      0409            0.1227    $7.54            $2.20      $1.51
86886    Coombs test, indirect, titer                     X      0409            0.1227    $7.54            $2.20      $1.51
86890    Autologous blood process                         X      0347            0.7423     45.63            11.28       9.13
86891    Autologous blood, op salvage                     X      0346            0.3484     21.42             4.39       4.28
86900    Blood typing, ABO                                X      0409            0.1227       7.54             2.2       1.51
86901    Blood typing, Rh (D)                             X      0409            0.1227       7.54             2.2       1.51
86903    Blood typing, antigen screen                     X      0345            0.2178     13.39             2.87       2.68
86904    Blood typing, patient serum                      X      0346            0.3484     21.42             4.39       4.28
86905    Blood typing, RBC antigens                       X      0345            0.2178     13.39             2.87       2.68
86906    Blood typing, Rh phenotype                       X      0345            0.2178     13.39             2.87       2.68
86910    Blood typing, paternity test                     E
86911    Blood typing, antigen system                     E
86920    Compatibility test, spin                         X      0346            0.3484     $21.42              $4.39              $4.28
86921    Compatibility test, incubate                     X      0345            0.2178       13.39               2.87               2.68
86922    Compatibility test, antiglob                     X      0346            0.3484     $21.42              $4.39              $4.28
86923    Compatibility test, electric                     X      0345            0.2178     $13.39              $2.87              $2.68
86927    Plasma, fresh frozen                             X      0345            0.2178     $13.39              $2.87              $2.68
86930    Frozen blood prep                                X      0347            0.7423     $45.63             $11.28              $9.13
86931    Frozen blood thaw                                X      0347            0.7423     $45.63             $11.28              $9.13
86932    Frozen blood freeze/thaw                         X      0347            0.7423     $45.63             $11.28              $9.13
86940    Hemolysins/agglutinins, auto                     A
86941    Hemolysins/agglutinins                           A
86945    Blood product/irradiation                        X      0345            0.2178     $13.39                2.87             $2.68
86950    Leukacyte transfusion                            X      0345            0.2178     $13.39                2.87             $2.68
86960    Vol reduction of blood/prod                      X      0345            0.2178     $13.39                2.87             $2.68
86965    Pooling blood platelets                  CH      X      0346            0.3484     $21.42                4.39             $4.28
86970    RBC pretreatment                                 X      0345            0.2178     $13.39                2.87             $2.68
86971    RBC pretreatment                                 X      0345            0.2178     $13.39                2.87             $2.68
86972    RBC pretreatment                                 X      0346            0.3484     $21.42                4.39             $4.28
86975    RBC pretreatment, serum                  CH      X      0346            0.3484     $21.42                4.39             $4.28
86976    RBC pretreatment, serum                          X      0345            0.2178     $13.39                2.87             $2.68
86977    RBC pretreatment, serum                  CH      X      0346            0.3484     $21.42                4.39             $4.28
86978    RBC pretreatment, serum                  CH      X      0346            0.3484     $21.42                4.39             $4.28
86985    Split blood or products                          X      0345            0.2178     $13.39                2.87             $2.68
86999    Transfusion procedure                            X      0345            0.2178     $13.39                2.87             $2.68
87001    Small animal inoculation                         A
87003    Small animal inoculation                         A
87015    Specimen concentration                           A
87040    Blood culture for bacteria                       A
87045    Feces culture, bacteria                          A
87046    Stool cultr, bacteria, each                      A
87070    Culture, bacteria, other                         A
87071    Culture bacteri aerobic othr                     A
87073    Culture bacteria anaerobic                       A
87075    Cultr bacteria, except blood                     A
87076    Culture anaerobe ident, each                     A
87077    Culture aerobic identify                         A
87081    Culture screen only                              A
87084    Culture of specimen by kit                       A
87086    Urine culture/colony count                       A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
87088    Urine bacteria culture                           A
87101    Skin fungi culture                               A
87102    Fungus isolation culture                         A
87103    Blood fungus culture                             A
87106    Fungi identification, yeast                      A
87107    Fungi identification, mold                       A
87109    Mycoplasma                                       A
87110    Chlamydia culture                                A
87116    Mycobacteria culture                             A
87118    Mycobacteric identification                      A
87140    Culture type immunofluoresc                      A
87143    Culture typing, glc/hplc                         A
87147    Culture type, immunologic                        A
87149    Culture type, nucleic acid                       A
87152    Culture type pulse field gel                     A
87158    Culture typing, added method                     A
87164    Dark field examination                           A
87166    Dark field examination                           A
87168    Macroscopic exam arthropod                       A
87169    Macroscopic exam parasite                        A
87172    Pinworm exam                                     A
87176    Tissue homogenization, cultr                     A
87177    Ova and parasites smears                         A
87181    Microbe susceptible, diffuse                     A
87184    Microbe susceptible, disk                        A
87185    Microbe susceptible, enzyme                      A
87186    Microbe susceptible, mic                         A
87187    Microbe susceptible, mlc                         A
87188    Microbe suscept, macrobroth                      A
87190    Microbe suscept, mycobacteri                     A
87197    Bactericidal level, serum                        A
87205    Smear, gram stain                                A
87206    Smear, fluorescent/acid stai                     A
87207    Smear, special stain                             A
87209    Smear, complex stain                             A
87210    Smear, wet mount, saline/ink                     A
87220    Tissue exam for fungi                            A
87230    Assay, toxin or antitoxin                        A
87250    Virus inoculate, eggs/animal                     A
87252    Virus inoculation, tissue                        A
87253    Virus inoculate tissue, addl                     A
87254    Virus inoculation, shell via                     A
87255    Genet virus isolate, hsv                         A
87260    Adenovirus ag, if                                A
87265    Pertussis ag, if                                 A
87267    Enterovirus antibody, dfa                        A
87269    Giardia ag, if                                   A
87270    Chlamydia trachomatis ag, if                     A
87271    Cryptosporidum/gardia ag, if                     A
87272    Cryptosporidium ag, if                           A
87273    Herpes simplex 2, ag, if                         A
87274    Herpes simplex 1, ag, if                         A
87275    Influenza b, ag, if                              A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
87276    Influenza a, ag, if                              A
87277    Legionella micdadei, ag, if                      A
87278    Legion pneumophilia ag, if                       A
87279    Parainfluenza, ag, if                            A
87280    Respiratory syncytial ag, if                     A
87281    Pneumocystis carinii, ag, if                     A
87283    Rubeola, ag, if                                  A
87285    Treponema pallidum, ag, if                       A
87290    Varicella zoster, ag, if                         A
87299    Antibody detection, nos, if                      A
87300    Ag detection, polyval, if                        A
87301    Adenovirus ag, eia                               A
87305    Aspergillus ag, eia                      NI      A
87320    Chylmd trach ag, eia                             A
87324    Clostridium ag, eia                              A
87327    Cryptococcus neoform ag, eia                     A
87328    Cryptosporidium ag, eia                          A
87329    Giardia ag, eia                                  A
87332    Cytomegalovirus ag, eia                          A
87335    E coli 0157 ag, eia                              A
87336    Entamoeb hist dispr, ag, eia                     A
87337    Entamoeb hist group, ag, eia                     A
87338    Hpylori, stool, eia                              A
87339    H pylori ag, eia                                 A
87340    Hepatitis b surface ag, eia                      A
87341    Hepatitis b surface, ag, eia                     A
87350    Hepatitis be ag, eia                             A
87380    Hepatitis delta ag, eia                          A
87385    Histoplasma capsul ag, eia                       A
87390    Hiv-1 ag, eia                                    A
87391    Hiv-2 ag, eia                                    A
87400    Influenza a/b, ag, eia                           A
87420    Resp syncytial ag, eia                           A
87425    Rotavirus ag, eia                                A
87427    Shiga-like toxin ag, eia                         A
87430    Strep a ag, eia                                  A
87449    Ag detect nos, eia, mult                         A
87450    Ag detect nos, eia, single                       A
87451    Ag detect polyval, eia, mult                     A
87470    Bartonella, dna, dir probe                       A
87471    Bartonella, dna, amp probe                       A
87472    Bartonella, dna, quant                           A
87475    Lyme dis, dna, dir probe                         A
87476    Lyme dis, dna, amp probe                         A
87477    Lyme dis, dna, quant                             A
87480    Candida, dna, dir probe                          A
87481    Candida, dna, amp probe                          A
87482    Candida, dna, quant                              A
87485    Chylmd pneum, dna, dir probe                     A
87486    Chylmd pneum, dna, amp probe                     A
87487    Chylmd pneum, dna, quant                         A
87490    Chylmd trach, dna, dir probe                     A
87491    Chylmd trach, dna, amp probe                     A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
87492    Chylmd trach, dna, quant                         A
87495    Cytomeg, dna, dir probe                          A
87496    Cytomeg, dna, amp probe                          A
87497    Cytomeg, dna, quant                              A
87498    Enterovirus, dna, amp probe              NI      A
87510    Gardner vag, dna, dir probe                      A
87511    Gardner vag, dna, amp probe                      A
87512    Gardner vag, dna, quant                          A
87515    Hepatitis b, dna, dir probe                      A
87516    Hepatitis b, dna, amp probe                      A
87517    Hepatitis b, dna, quant                          A
87520    Hepatitis c, rna, dir probe                      A
87521    Hepatitis c, rna, amp probe                      A
87522    Hepatitis c, rna, quant                          A
87525    Hepatitis g, dna, dir probe                      A
87526    Hepatitis g, dna, amp probe                      A
87527    Hepatitis g, dna, quant                          A
87528    Hsv, dna, dir probe                              A
87529    Hsv, dna, amp probe                              A
87530    Hsv, dna, quant                                  A
87531    Hhv-6, dna, dir probe                            A
87532    Hhv-6, dna, amp probe                            A
87533    Hhv-6, dna, quant                                A
87534    Hiv-1, dna, dir probe                            A
87535    Hiv-1, dna, amp probe                            A
87536    Hiv-1, dna, quant                                A
87537    Hiv-2, dna, dir probe                            A
87538    Hiv-2, dna, amp probe                            A
87539    Hiv-2, dna, quant                                A
87540    Legion pneumo, dna, dir prob                     A
87541    Legion pneumo, dna, amp prob                     A
87542    Legion pneumo, dna, quant                        A
87550    Mycobacteria, dna, dir probe                     A
87551    Mycobacteria, dna, amp probe                     A
87552    Mycobacteria, dna, quant                         A
87555    M.tuberculo, dna, dir probe                      A
87556    M.tuberculo, dna, amp probe                      A
87557    M.tuberculo, dna, quant                          A
87560    M.avium-intra, dna, dir prob                     A
87561    M.avium-intra, dna, amp prob                     A
87562    M.avium-intra, dna, quant                        A
87580    M.pneumon, dna, dir probe                        A
87581    M.pneumon, dna, amp probe                        A
87582    M.pneumon, dna, quant                            A
87590    N.gonorrhoeae, dna, dir prob                     A
87591    N.gonorrhoeae, dna, amp prob                     A
87592    N.gonorrhoeae, dna, quant                        A
87620    Hpv, dna, dir probe                              A
87621    Hpv, dna, amp probe                              A
87622    Hpv, dna, quant                                  A
87640    Staph a, dna, amp probe                  NI      A
87641    Mr-staph, dna, amp probe                 NI      A
87650    Strep a, dna, dir probe                          A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468            2007 CF
                                                                                                        National            Minimum
HCPCS/                                                                         Relative                Unadjusted           Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment            Copayment
87651    Strep a, dna, amp probe                          A
87652    Strep a, dna, quant                              A
87653    Strep b, dna, amp probe                  NI      A
87660    Trichomonas vagin, dir probe                     A
87797    Detect agent nos, dna, dir                       A
87798    Detect agent nos, dna, amp                       A
87799    Detect agent nos, dna, quant                     A
87800    Detect agnt mult, dna, direc                     A
87801    Detect agnt mult, dna, ampli                     A
87802    Strep b assay w/optic                            A
87803    Clostridium toxin a w/optic                      A
87804    Influenza assay w/optic                          A
87807    Rsv assay w/optic                                A
87808    Trichomonas assay w/optic                NI      A
87810    Chylmd trach assay w/optic                       A
87850    N. gonorrhoeae assay w/optic                     A
87880    Strep a assay w/optic                            A
87899    Agent nos assay w/optic                          A
87900    Phenotype, infect agent drug                     A
87901    Genotype, dna, hiv reverse t                     A
87902    Genotype, dna, hepatitis C                       A
87903    Phenotype, dna hiv w/culture                     A
87904    Phenotype, dna hiv w/clt add                     A
87999    Microbiology procedure                           X      0342            0.0824         $5.06             $2.02              $1.01
88000    Autopsy (necropsy), gross                        E
88005    Autopsy (necropsy), gross                        E
88007    Autopsy (necropsy), gross                        E
88012    Autopsy (necropsy), gross                        E
88014    Autopsy (necropsy), gross                        E
88016    Autopsy (necropsy), gross                        E
88020    Autopsy (necropsy), complete                     E
88025    Autopsy (necropsy), complete                     E
88027    Autopsy (necropsy), complete                     E
88028    Autopsy (necropsy), complete                     E
88029    Autopsy (necropsy), complete                     E
88036    Limited autopsy                                  E
88037    Limited autopsy                                  E
88040    Forensic autopsy (necropsy)                      E
88045    Coroner's autopsy (necropsy)                     E
88099    Necropsy (autopsy) procedure                     E
88104    Cytopath fl nongyn, smears                       X      0433            0.2557        $15.72             $5.93              $3.14
88106    Cytopath fl nongyn, filter                       X      0433            0.2557        $15.72             $5.93              $3.14
88107    Cytopath fl nongyn, sm/fltr                      X      0433            0.2557        $15.72             $5.93              $3.14
88108    Cytopath, concentrate tech                       X      0433            0.2557          15.72              5.93               3.14
88112    Cytopath, cell enhance tech                      X      0343            0.5211        $32.03              10.84             $6.41
88125    Forensic cytopathology                   CH      X      0433            0.2557        $15.72               5.93             $3.14
88130    Sex chromatin identification                     A
88140    Sex chromatin identification                     A
88141    Cytopath, c/v, interpret                         N
88142    Cytopath, c/v, thin layer                        A
88143    Cytopath c/v thin layer redo                     A
88147    Cytopath, c/v, automated                         A
88148    Cytopath, c/v, auto rescreen                     A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 126 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                Short Descriptor               CI      SI     APC           Weight     Payment Rate Copayment             Copayment
88150    Cytopath, c/v, manual                            A
88152    Cytopath, c/v, auto redo                         A
88153    Cytopath, c/v, redo                              A
88154    Cytopath, c/v, select                            A
88155    Cytopath, c/v, index add-on                      A
88160    Cytopath smear, other source                     X      0433            0.2557        $15.72                5.93             $3.14
88161    Cytopath smear, other source                     X      0433            0.2557        $15.72                5.93             $3.14
88162    Cytopath smear, other source                     X      0433            0.2557        $15.72                5.93             $3.14
88164    Cytopath tbs, c/v, manual                        A
88165    Cytopath tbs, c/v, redo                          A
88166    Cytopath tbs, c/v, auto redo                     A
88167    Cytopath tbs, c/v, select                        A
88172    Cytopathology eval of fna                        X      0343            0.5211         32.03              10.84               6.41
88173    Cytopath eval, fna, report                       X      0343            0.5211         32.03              10.84               6.41
88174    Cytopath, c/v auto, in fluid                     A
88175    Cytopath c/v auto fluid redo                     A
88182    Cell marker study                        CH      X      0343            0.5211          32.03              10.84               6.41
88184    Flowcytometry/ tc, 1 marker              CH      X      0433            0.2557          15.72               5.93               3.14
88185    Flowcytometry/tc, add-on                 CH      X      0433            0.2557        $15.72              $5.93              $3.14
88187    Flowcytometry/read, 2-8                          X      0433            0.2557        $15.72                5.93             $3.14
88188    Flowcytometry/read, 9-15                         X      0433            0.2557          15.72               5.93               3.14
88189    Flowcytometry/read, 16 & >                       X      0343            0.5211          32.03              10.84               6.41
88199    Cytopathology procedure                          X      0342            0.0824           5.06               2.02               1.01
88230    Tissue culture, lymphocyte                       A
88233    Tissue culture, skin/biopsy                      A
88235    Tissue culture, placenta                         A
88237    Tissue culture, bone marrow                      A
88239    Tissue culture, tumor                            A
88240    Cell cryopreserve/storage                        A
88241    Frozen cell preparation                          A
88245    Chromosome analysis, 20-25                       A
88248    Chromosome analysis, 50-100                      A
88249    Chromosome analysis, 100                         A
88261    Chromosome analysis, 5                           A
88262    Chromosome analysis, 15-20                       A
88263    Chromosome analysis, 45                          A
88264    Chromosome analysis, 20-25                       A
88267    Chromosome analys, placenta                      A
88269    Chromosome analys, amniotic                      A
88271    Cytogenetics, dna probe                          A
88272    Cytogenetics, 3-5                                A
88273    Cytogenetics, 10-30                              A
88274    Cytogenetics, 25-99                              A
88275    Cytogenetics, 100-300                            A
88280    Chromosome karyotype study                       A
88283    Chromosome banding study                         A
88285    Chromosome count, additional                     A
88289    Chromosome study, additional                     A
88291    Cyto/molecular report                            M
88299    Cytogenetic study                                X      0342       0.0824                5.06               2.02               1.01
88300    Surgical path, gross                             X      0433       0.2557               15.72               5.93               3.14
88302    Tissue exam by pathologist                       X      0433       0.2557             $15.72              $5.93              $3.14
88304    Tissue exam by pathologist                       X        Milliman 0.5211
                                                                 0343                          $32.03             $10.84              $6.41
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight Payment Rate     Copayment Copayment
88305    Tissue exam by pathologist                       X      0343            0.5211    $32.03          $10.84      $6.41
88307    Tissue exam by pathologist                       X      0344            0.7927    $48.73          $15.66      $9.75
88309    Tissue exam by pathologist                       X      0344            0.7927    $48.73          $15.66      $9.75
88311    Decalcify tissue                         CH      X      0433            0.2557    $15.72           $5.93      $3.14
88312    Special stains                                   X      0433            0.2557    $15.72           $5.93      $3.14
88313    Special stains                                   X      0433            0.2557    $15.72           $5.93      $3.14
88314    Histochemical stain                              X      0342            0.0824     $5.06           $2.02      $1.01
88318    Chemical histochemistry                          X      0433            0.2557    $15.72           $5.93      $3.14
88319    Enzyme histochemistry                            X      0343            0.5211    $32.03          $10.84      $6.41
88321    Microslide consultation                          X      0433            0.2557    $15.72           $5.93      $3.14
88323    Microslide consultation                          X      0343            0.5211    $32.03          $10.84      $6.41
88325    Comprehensive review of data                     X      0344            0.7927    $48.73          $15.66      $9.75
88329    Path consult introp                              X      0433            0.2557    $15.72           $5.93      $3.14
88331    Path consult intraop, 1 bloc                     X      0343            0.5211    $32.03          $10.84      $6.41
88332    Path consult intraop, addÆl                      X      0433            0.2557    $15.72           $5.93      $3.14
88333    Intraop cyto path consult, 1                     X      0343            0.5211    $32.03          $10.84      $6.41
88334    Intraop cyto path consult, 2                     X      0433            0.2557    $15.72           $5.93      $3.14
88342    Immunohistochemistry                             X      0343            0.5211    $32.03            10.84     $6.41
88346    Immunofluorescent study                          X      0343            0.5211    $32.03          $10.84      $6.41
88347    Immunofluorescent study                          X      0343            0.5211    $32.03          $10.84      $6.41
88348    Electron microscopy                              X      0661            2.5255   $155.24          $62.09     $31.05
88349    Scanning electron microscopy                     X      0661            2.5255     155.24           62.09      31.05
88355    Analysis, skeletal muscle                        X      0343            0.5211      32.03           10.84       6.41
88356    Analysis, nerve                                  X      0344            0.7927      48.73           15.66       9.75
88358    Analysis, tumor                                  X      0344            0.7927      48.73           15.66       9.75
88360    Tumor immunohistochem/manual             CH      X      0343            0.5211      32.03           10.84       6.41
88361    Tumor immunohistochem/comput                     X      0344            0.7927      48.73           15.66       9.75
88362    Nerve teasing preparations                       X      0344            0.7927    $48.73          $15.66      $9.75
88365    Insitu hybridization (fish)                      X      0344            0.7927      48.73           15.66       9.75
88367    Insitu hybridization, auto                       X      0344            0.7927      48.73           15.66       9.75
88368    Insitu hybridization, manual                     X      0344            0.7927    $48.73          $15.66      $9.75
88371    Protein, western blot tissue                     A
88372    Protein analysis w/probe                         A
88380    Microdissection                                  N
88384    Eval molecular probes, 11-50                     X      0433            0.2557      15.72               5.93              3.14
88385    Eval molecul probes, 51-250                      X      0343            0.5211      32.03              10.84              6.41
88386    Eval molecul probes, 251-500                     X      0344            0.7927      48.73              15.66              9.75
88399    Surgical pathology procedure                     X      0342            0.0824       5.06               2.02              1.01
88400    Bilirubin total transcut                         A
89049    Chct for mal hyperthermia                        X      0343            0.5211      32.03              10.84              6.41
89050    Body fluid cell count                            A
89051    Body fluid cell count                            A
89055    Leukocyte assessment, fecal                      A
89060    Exam,synovial fluid crystals                     A
89100    Sample intestinal contents                       X      0360            1.4154         87              33.88              17.4
89105    Sample intestinal contents                       X      0360            1.4154         87              33.88              17.4
89125    Specimen fat stain                               A
89130    Sample stomach contents                          X      0360       1.4154               87              33.88            17.4
89132    Sample stomach contents                          X      0360       1.4154          $87.00             $33.88          $17.40
89135    Sample stomach contents                          X      0360       1.4154          $87.00             $33.88          $17.40
89136    Sample stomach contents                          X      0360       1.4154          $87.00             $33.88          $17.40
89140    Sample stomach contents                          X      0360       1.4154          $87.00             $33.88          $17.40
89141    Sample stomach contents                          X        Milliman 1.4154
                                                                 0360                       $87.00             $33.88          $17.40
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468           2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
89160    Exam feces for meat fibers                       A
89190    Nasal smear for eosinophils                      A
89220    Sputum specimen collection                       X      0343            0.5211        $32.03             10.84             $6.41
89225    Starch granules, feces                           A
89230    Collect sweat for test                           X      0433            0.2557         15.72              5.93              3.14
89235    Water load test                                  A
89240    Pathology lab procedure                          X      0342            0.0824         $5.06             $2.02          $1.01
89250    Cultr oocyte/embryo <4 days                      X      0348            0.8321        $51.15                           $10.23
89251    Cultr oocyte/embryo <4 days                      X      0348            0.8321        $51.15                           $10.23
89253    Embryo hatching                                  X      0348            0.8321        $51.15                           $10.23
89254    Oocyte identification                            X      0348            0.8321        $51.15                           $10.23
89255    Prepare embryo for transfer                      X      0348            0.8321        $51.15                           $10.23
89257    Sperm identification                             X      0348            0.8321        $51.15                           $10.23
89258    Cryopreservation; embryo(s)                      X      0348            0.8321        $51.15                           $10.23
89259    Cryopreservation, sperm                          X      0348            0.8321        $51.15                           $10.23
89260    Sperm isolation, simple                          X      0348            0.8321          51.15                            10.23
89261    Sperm isolation, complex                         X      0348            0.8321          51.15                            10.23
89264    Identify sperm tissue                            X      0348            0.8321        $51.15                           $10.23
89268    Insemination of oocytes                          X      0348            0.8321        $51.15                           $10.23
89272    Extended culture of oocytes                      X      0348            0.8321        $51.15                           $10.23
89280    Assist oocyte fertilization                      X      0348            0.8321        $51.15                           $10.23
89281    Assist oocyte fertilization                      X      0348            0.8321          51.15                            10.23
89290    Biopsy, oocyte polar body                        X      0348            0.8321        $51.15                           $10.23
89291    Biopsy, oocyte polar body                        X      0348            0.8321          51.15                            10.23
89300    Semen analysis w/huhner                          A
89310    Semen analysis w/count                           A
89320    Semen analysis, complete                         A
89321    Semen analysis & motility                        A
89325    Sperm antibody test                              A
89329    Sperm evaluation test                            A
89330    Evaluation, cervical mucus                       A
89335    Cryopreserve testicular tiss                     X      0348            0.8321        $51.15                           $10.23
89342    Storage/year; embryo(s)                          X      0348            0.8321          51.15                            10.23
89343    Storage/year; sperm/semen                        X      0348            0.8321        $51.15                           $10.23
89344    Storage/year; reprod tissue                      X      0348            0.8321          51.15                            10.23
89346    Storage/year; oocyte(s)                          X      0348            0.8321          51.15                            10.23
89352    Thawing cryopresrved; embryo                     X      0348            0.8321        $51.15                           $10.23
89353    Thawing cryopresrved; sperm                      X      0348            0.8321        $51.15                           $10.23
89354    Thaw cryoprsvrd; reprod tiss                     X      0348            0.8321          51.15                            10.23
89356    Thawing cryopresrved; oocyte                     X      0348            0.8321          51.15                            10.23
90281    Human ig, im                                     E
90283    Human ig, iv                                     E
90287    Botulinum antitoxin                              E
90288    Botulism ig, iv                                  E
90291    Cmv ig, iv                                       E
90296    Diphtheria antitoxin                             N
90371    Hep b ig, im                                     K      1630                           119.06                            23.81
90375    Rabies ig, im/sc                                 K      9133                          $64.53                           $12.91
90376    Rabies ig, heat treated                          K      9134                          $68.24                           $13.65
90378    Rsv ig, im, 50mg                                 E
90379    Rsv ig, iv                                       E
90384    Rh ig, full-dose, im                             E
90385    Rh ig, minidose, im                              N        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468      2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
90386    Rh ig, iv                                        E
90389    Tetanus ig, im                                   E
90393    Vaccina ig, im                                   N
90396    Varicella-zoster ig, im                          K      9135                         $140.92                     $28.18
90399    Immune globulin                                  E
90465    Immune admin 1 inj, < 8 yrs                      B
90466    Immune admin addl inj, < 8 y                     B
90467    Immune admin o or n, < 8 yrs                     B
90468    Immune admin o/n, addl < 8 y                     B
90471    Immunization admin                       CH      S      0437            0.3945        $24.25                         $4.85
90472    Immunization admin, each add             CH      S      0436            0.1809        $11.12                         $2.22
90473    Immune admin oral/nasal                  CH      S      0436            0.1809        $11.12                         $2.22
90474    Immune admin oral/nasal addl             CH      S      0436            0.1809        $11.12                         $2.22
90476    Adenovirus vaccine, type 4               CH      N
90477    Adenovirus vaccine, type 7                       N
90581    Anthrax vaccine, sc                      CH      N
90585    Bcg vaccine, percut                              K      9137                         $117.39                     $23.48
90586    Bcg vaccine, intravesical                        B
90632    Hep a vaccine, adult im                          N
90633    Hep a vacc, ped/adol, 2 dose                     N
90634    Hep a vacc, ped/adol, 3 dose                     N
90636    Hep a/hep b vacc, adult im               CH      N
90645    Hib vaccine, hboc, im                            N
90646    Hib vaccine, prp-d, im                           N
90647    Hib vaccine, prp-omp, im                         N
90648    Hib vaccine, prp-t, im                           N
90649    Hpapilloma vacc 3 dose im                CH      B
90655    Flu vaccine no preserv 6-35m                     L
90656    Flu vaccine no preserv 3 & >                     L
90657    Flu vaccine, 3 yrs, im                           L
90658    Flu vaccine, 3 yrs & >, im                       L
90660    Flu vaccine, nasal                               L
90665    Lyme disease vaccine, im                 CH      N
90669    Pneumococcal vacc, ped <5                        E
90675    Rabies vaccine, im                               K      9139                          157.74                         31.55
90676    Rabies vaccine, id                               K      9140                          166.16                         33.23
90680    Rotovirus vacc 3 dose, oral                      N
90690    Typhoid vaccine, oral                            N
90691    Typhoid vaccine, im                              N
90692    Typhoid vaccine, h-p, sc/id                      N
90693    Typhoid vaccine, akd, sc                 CH      B
90698    Dtap-hib-ip vaccine, im                          N
90700    Dtap vaccine, < 7 yrs, im                        N
90701    Dtp vaccine, im                                  N
90702    Dt vaccine < 7, im                               N
90703    Tetanus vaccine, im                              N
90704    Mumps vaccine, sc                                N
90705    Measles vaccine, sc                              N
90706    Rubella vaccine, sc                              N
90707    Mmr vaccine, sc                                  N
90708    Measles-rubella vaccine, sc                      K      9141                          $60.82                     $12.16
90710    Mmrv vaccine, sc                                 N
90712    Oral poliovirus vaccine                          N        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468     2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
90713    Poliovirus, ipv, sc/im                           N
90714    Td vaccine no prsrv >/= 7 im             CH      N
90715    Tdap vaccine >7 im                               N
90716    Chicken pox vaccine, sc                  CH      B
90717    Yellow fever vaccine, sc                 CH      N
90718    Td vaccine > 7, im                               N
90719    Diphtheria vaccine, im                           N
90720    Dtp/hib vaccine, im                      CH      K      3032                          $45.01                         $9.00
90721    Dtap/hib vaccine, im                             N
90723    Dtap-hep b-ipv vaccine, im                       E
90725    Cholera vaccine, injectable                      N
90727    Plague vaccine, im                       CH      K      0744                         $150.00                     $30.00
90732    Pneumococcal vaccine                             L
90733    Meningococcal vaccine, sc                        K      9143                          $84.46                     $16.89
90734    Meningococcal vaccine, im                        K      9145                          $53.71                     $10.74
90735    Encephalitis vaccine, sc                         K      9144                          $96.22                     $19.24
90736    Zoster vacc, sc                          CH      B
90740    Hepb vacc, ill pat 3 dose im                     F
90743    Hep b vacc, adol, 2 dose, im                     F
90744    Hepb vacc ped/adol 3 dose im                     F
90746    Hep b vaccine, adult, im                         F
90747    Hepb vacc, ill pat 4 dose im                     F
90748    Hep b/hib vaccine, im                            E
90749    Vaccine toxoid                                   N
90760    Hydration iv infusion, init              CH      S      0440            1.8090       $111.20                     $22.24
90761    Hydrate iv infusion, add-on              CH      S      0437            0.3945        $24.25                      $4.85
90765    Ther/proph/diag iv inf, init             CH      S      0440            1.8090       $111.20                     $22.24
90766    Ther/proph/dg iv inf, add-on             CH      S      0437            0.3945        $24.25                      $4.85
90767    Tx/proph/dg addl seq iv inf              CH      S      0437            0.3945        $24.25                      $4.85
90768    Ther/diag concurrent inf                 CH      N
90772    Ther/proph/diag inj, sc/im               CH      S      0437       0.3945             $24.25                      $4.85
90773    Ther/proph/diag inj, ia                  CH      S      0438       0.7942             $48.82                      $9.76
90774    Ther/proph/diag inj, iv push             CH      S      0438       0.7942             $48.82                      $9.76
90775    Ther/proph/diag inj add-on               CH      S      0438       0.7942             $48.82                      $9.76
90779    Ther/prop/diag inj/inf proc              CH      S      0436       0.1809               11.12                       2.22
90801    Psy dx interview                                 S      0323       1.7066               104.9                      20.98
90802    Intac psy dx interview                           S      0323       1.7066               104.9                      20.98
90804    Psytx, office, 20-30 min                         S      0322       1.1798               72.52                       14.5
90805    Psytx, off, 20-30 min w/e&m                      S      0322       1.1798             $72.52                     $14.50
90806    Psytx, off, 45-50 min                            S      0323       1.7066               104.9                      20.98
90807    Psytx, off, 45-50 min w/e&m                      S      0323       1.7066               104.9                      20.98
90808    Psytx, office, 75-80 min                         S      0323       1.7066            $104.90                     $20.98
90809    Psytx, off, 75-80, w/e&m                         S      0323       1.7066            $104.90                     $20.98
90810    Intac psytx, off, 20-30 min                      S      0322       1.1798             $72.52                     $14.50
90811    Intac psytx, 20-30, w/e&m                        S      0322       1.1798             $72.52                     $14.50
90812    Intac psytx, off, 45-50 min                      S      0323       1.7066            $104.90                     $20.98
90813    Intac psytx, 45-50 min w/e&m                     S      0323       1.7066            $104.90                     $20.98
90814    Intac psytx, off, 75-80 min                      S      0323       1.7066            $104.90                     $20.98
90815    Intac psytx, 75-80 w/e&m                         S      0323       1.7066            $104.90                     $20.98
90816    Psytx, hosp, 20-30 min                           S      0322       1.1798             $72.52                     $14.50
90817    Psytx, hosp, 20-30 min w/e&m                     S      0322       1.1798             $72.52                     $14.50
90818    Psytx, hosp, 45-50 min                           S      0323       1.7066            $104.90                     $20.98
90819    Psytx, hosp, 45-50 min w/e&m                     S        Milliman 1.7066
                                                                 0323                         $104.90                     $20.98
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
90821    Psytx, hosp, 75-80 min                           S      0323            1.7066       $104.90                 $20.98
90822    Psytx, hosp, 75-80 min w/e&m                     S      0323            1.7066       $104.90                 $20.98
90823    Intac psytx, hosp, 20-30 min                     S      0322            1.1798        $72.52                 $14.50
90824    Intac psytx, hsp 20-30 w/e&m                     S      0322            1.1798        $72.52                 $14.50
90826    Intac psytx, hosp, 45-50 min                     S      0323            1.7066       $104.90                 $20.98
90827    Intac psytx, hsp 45-50 w/e&m                     S      0323            1.7066       $104.90                 $20.98
90828    Intac psytx, hosp, 75-80 min                     S      0323            1.7066       $104.90                 $20.98
90829    Intac psytx, hsp 75-80 w/e&m                     S      0323            1.7066       $104.90                 $20.98
90845    Psychoanalysis                                   S      0323            1.7066       $104.90                 $20.98
90846    Family psytx w/o patient                         S      0324            2.1633       $132.97                 $26.59
90847    Family psytx w/patient                           S      0324            2.1633       $132.97                 $26.59
90849    Multiple family group psytx                      S      0325            1.0765        $66.17      $14.47     $13.23
90853    Group psychotherapy                              S      0325            1.0765        $66.17      $14.47     $13.23
90857    Intac group psytx                                S      0325            1.0765        $66.17      $14.47     $13.23
90862    Medication management                            X      0374            1.1418        $70.18                 $14.04
90865    Narcosynthesis                                   S      0323            1.7066       $104.90                 $20.98
90870    Electroconvulsive therapy                        S      0320            5.5676         342.23       80.06      68.45
90875    Psychophysiological therapy                      E
90876    Psychophysiological therapy                      E
90880    Hypnotherapy                                     S      0323            1.7066      $104.90                             $20.98
90882    Environmental manipulation                       E
90885    Psy evaluation of records                        N
90887    Consultation with family                         N
90889    Preparation of report                            N
90899    Psychiatric service/therapy                      S      0322            1.1798       $72.52                             $14.50
90901    Biofeedback train, any meth                      A
90911    Biofeedback peri/uro/rectal                      S      0321            1.3384       $82.27             $21.72          $16.45
90918    ESRD related services, month                     E
90919    ESRD related services, month                     E
90920    ESRD related services, month                     E
90921    ESRD related services, month                     E
90922    ESRD related services, day                       E
90923    Esrd related services, day                       E
90924    Esrd related services, day                       E
90925    Esrd related services, day                       E
90935    Hemodialysis, one evaluation                     S      0170            6.6089      $406.24                             $81.25
90937    Hemodialysis, repeated eval                      B
90940    Hemodialysis access study                        N
90945    Dialysis, one evaluation                         S      0170            6.6089      $406.24                             $81.25
90947    Dialysis, repeated eval                          B
90989    Dialysis training, complete                      B
90993    Dialysis training, incompl                       B
90997    Hemoperfusion                                    B
90999    Dialysis procedure                               B
91000    Esophageal intubation                            X      0361       3.8887           $239.03             $83.23          $47.81
91010    Esophagus motility study                         X      0361       3.8887           $239.03             $83.23          $47.81
91011    Esophagus motility study                         X      0361       3.8887           $239.03             $83.23          $47.81
91012    Esophagus motility study                         X      0361       3.8887           $239.03             $83.23          $47.81
91020    Gastric motility studies                         X      0361       3.8887           $239.03             $83.23          $47.81
91022    Duodenal motility study                          X      0361       3.8887           $239.03             $83.23          $47.81
91030    Acid perfusion of esophagus                      X      0361       3.8887           $239.03             $83.23          $47.81
91034    Gastroesophageal reflux test                     X      0361       3.8887             239.03              83.23           47.81
91035    G-esoph reflx tst w/electrod             CH      X      0361
                                                                   Milliman 3.8887             239.03              83.23           47.81
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 132 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
91037    Esoph imped function test                        X      0361            3.8887         239.03       83.23      47.81
91038    Esoph imped funct test > 1h                      X      0361            3.8887       $239.03      $83.23     $47.81
91040    Esoph balloon distension tst                     X      0360            1.4154        $87.00      $33.88     $17.40
91052    Gastric analysis test                            X      0361            3.8887       $239.03      $83.23     $47.81
91055    Gastric intubation for smear                     X      0360            1.4154        $87.00      $33.88     $17.40
91060    Gastric saline load test                 CH      D
91065    Breath hydrogen test                             X      0360            1.4154       $87.00          $33.88            $17.40
91100    Pass intestine bleeding tube                     X      0360            1.4154       $87.00          $33.88            $17.40
91105    Gastric intubation treatment                     X      0360            1.4154       $87.00          $33.88            $17.40
91110    Gi tract capsule endoscopy                       T      0142            9.4946      $583.61         $152.78           $116.72
91111    Esophageal capsule endoscopy             NI      T      0141            8.3175      $511.26         $143.38           $102.25
91120    Rectal sensation test                    CH      T      0126            1.0887       $66.92          $16.45            $13.38
91122    Anal pressure record                     CH      T      0164            2.1393      $131.50                            $26.30
91123    Irrigate fecal impaction                         N
91132    Electrogastrography                              X      0360            1.4154       $87.00             $33.88          $17.40
91133    Electrogastrography w/test                       X      0360            1.4154       $87.00             $33.88          $17.40
91299    Gastroenterology procedure                       X      0360            1.4154       $87.00             $33.88          $17.40
92002    Eye exam, new patient                    CH      V      0605            0.9840       $60.48                             $12.10
92004    Eye exam, new patient                    CH      V      0606            1.3646       $83.88                             $16.78
92012    Eye exam established pat                 CH      V      0604            0.8242       $50.66                             $10.13
92014    Eye exam & treatment                     CH      V      0605            0.9840       $60.48                             $12.10
92015    Refraction                                       E
92018    New eye exam & treatment                         T      0699           14.3845        884.19                            176.84
92019    Eye exam & treatment                             T      0699           14.3845        884.19                            176.84
92020    Special eye evaluation                           S      0230            0.7898         48.55             14.97            9.71
92025    Corneal topography                       NI      S      0698            1.1607         71.35                             14.27
92060    Special eye evaluation                           S      0230            0.7898         48.55             14.97            9.71
92065    Orthoptic/pleoptic training              CH      S      0230            0.7898         48.55             14.97            9.71
92070    Fitting of contact lens                          N
92081    Visual field examination(s)                      S      0230            0.7898       $48.55              14.97              $9.71
92082    Visual field examination(s)                      S      0230            0.7898       $48.55              14.97              $9.71
92083    Visual field examination(s)                      S      0230            0.7898       $48.55              14.97              $9.71
92100    Serial tonometry exam(s)                         N
92120    Tonography & eye evaluation                      S      0230       0.7898            $48.55              14.97           $9.71
92130    Water provocation tonography                     S      0230       0.7898            $48.55              14.97           $9.71
92135    Opthalmic dx imaging                             S      0230       0.7898            $48.55              14.97           $9.71
92136    Ophthalmic biometry                              S      0698       1.1607            $71.35                             $14.27
92140    Glaucoma provocative tests               CH      S      0230       0.7898            $48.55             $14.97           $9.71
92225    Special eye exam, initial                CH      S      0230       0.7898            $48.55               14.97          $9.71
92226    Special eye exam, subsequent             CH      S      0230       0.7898            $48.55             $14.97           $9.71
92230    Eye exam with photos                     CH      S      0231       2.1451           $131.86                             $26.37
92235    Eye exam with photos                             S      0231       2.1451           $131.86                             $26.37
92240    Icg angiography                                  S      0231       2.1451           $131.86                             $26.37
92250    Eye exam with photos                             S      0230       0.7898            $48.55             $14.97           $9.71
92260    Ophthalmoscopy/dynamometry               CH      S      0230       0.7898            $48.55             $14.97           $9.71
92265    Eye muscle evaluation                            S      0230       0.7898            $48.55             $14.97           $9.71
92270    Electro-oculography                              S      0230       0.7898            $48.55             $14.97           $9.71
92275    Electroretinography                              S      0231       2.1451           $131.86                             $26.37
92283    Color vision examination                         S      0230       0.7898            $48.55             $14.97           $9.71
92284    Dark adaptation eye exam                         S      0698       1.1607            $71.35                             $14.27
92285    Eye photography                                  S      0230       0.7898            $48.55             $14.97           $9.71
92286    Internal eye photography                         S      0698       1.1607            $71.35                             $14.27
92287    Internal eye photography                         S        Milliman 1.1607
                                                                 0698                         $71.35                             $14.27
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                     Page 133 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment             Copayment
92310    Contact lens fitting                             E
92311    Contact lens fitting                             X      0362            0.5865         36.05                                  7.21
92312    Contact lens fitting                             X      0362            0.5865         36.05                                  7.21
92313    Contact lens fitting                             X      0362            0.5865         36.05                                  7.21
92314    Prescription of contact lens                     E
92315    Prescription of contact lens                     X      0362            0.5865          36.05                                  7.21
92316    Prescription of contact lens                     X      0362            0.5865          36.05                                  7.21
92317    Prescription of contact lens                     X      0362            0.5865        $36.05                                 $7.21
92325    Modification of contact lens                     X      0362            0.5865        $36.05                                 $7.21
92326    Replacement of contact lens                      X      0362            0.5865        $36.05                                 $7.21
92340    Fitting of spectacles                            E
92341    Fitting of spectacles                            E
92342    Fitting of spectacles                            E
92352    Special spectacles fitting                       X      0362            0.5865        $36.05                                 $7.21
92353    Special spectacles fitting                       X      0362            0.5865        $36.05                                 $7.21
92354    Special spectacles fitting                       X      0362            0.5865        $36.05                                 $7.21
92355    Special spectacles fitting                       X      0362            0.5865        $36.05                                 $7.21
92358    Eye prosthesis service                           X      0362            0.5865        $36.05                                 $7.21
92370    Repair & adjust spectacles                       E
92371    Repair & adjust spectacles                       X      0362            0.5865        $36.05                              $7.21
92499    Eye service or procedure                         S      0230            0.7898        $48.55              14.97           $9.71
92502    Ear and throat examination                       T      0251            2.4520       $150.72                             $30.14
92504    Ear microscopy examination                       N
92506    Speech/hearing evaluation                        A
92507    Speech/hearing therapy                           A
92508    Speech/hearing therapy                           A
92511    Nasopharyngoscopy                                T      0071            0.7698        $47.32             $11.20           $9.46
92512    Nasal function studies                           X      0363            0.8525        $52.40             $17.44          $10.48
92516    Facial nerve function test                       X      0660            1.4461        $88.89             $28.06          $17.78
92520    Laryngeal function studies                       X      0660            1.4461        $88.89               28.06         $17.78
92526    Oral function therapy                            A
92531    Spontaneous nystagmus study                      N
92532    Positional nystagmus test                        N
92533    Caloric vestibular test                          N
92534    Optokinetic nystagmus test                       N
92541    Spontaneous nystagmus test                       X      0363            0.8525        $52.40             $17.44          $10.48
92542    Positional nystagmus test                        X      0363            0.8525        $52.40             $17.44          $10.48
92543    Caloric vestibular test                          X      0660            1.4461        $88.89             $28.06          $17.78
92544    Optokinetic nystagmus test                       X      0363            0.8525        $52.40             $17.44          $10.48
92545    Oscillating tracking test                        X      0363            0.8525        $52.40             $17.44          $10.48
92546    Sinusoidal rotational test                       X      0660            1.4461        $88.89             $28.06          $17.78
92547    Supplemental electrical test                     X      0363            0.8525        $52.40             $17.44          $10.48
92548    Posturography                                    X      0660            1.4461        $88.89             $28.06          $17.78
92551    Pure tone hearing test, air                      E
92552    Pure tone audiometry, air                        X      0364            0.4627        $28.44                7.06          $5.69
92553    Audiometry, air & bone                           X      0365            1.2419        $76.34               18.52         $15.27
92555    Speech threshold audiometry                      X      0364            0.4627        $28.44                7.06          $5.69
92556    Speech audiometry, complete                      X      0364            0.4627        $28.44              $7.06           $5.69
92557    Comprehensive hearing test                       X      0365            1.2419        $76.34             $18.52          $15.27
92559    Group audiometric testing                        E
92560    Bekesy audiometry, screen                        E
92561    Bekesy audiometry, diagnosis                     X      0364       0.4627             $28.44              $7.06              $5.69
92562    Loudness balance test                            X        Milliman 0.4627
                                                                 0364                          $28.44              $7.06              $5.69
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 134 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
92563    Tone decay hearing test                          X      0364            0.4627        $28.44         7.06     $5.69
92564    Sisi hearing test                                X      0364            0.4627        $28.44       $7.06      $5.69
92565    Stenger test, pure tone                          X      0364            0.4627        $28.44         7.06     $5.69
92567    Tympanometry                                     X      0364            0.4627        $28.44         7.06     $5.69
92568    Acoustic refl threshold tst                      X      0364            0.4627        $28.44         7.06     $5.69
92569    Acoustic reflex decay test                       X      0364            0.4627        $28.44         7.06     $5.69
92571    Filtered speech hearing test                     X      0364            0.4627          28.44        7.06       5.69
92572    Staggered spondaic word test                     X      0366            1.8511       $113.78        26.14    $22.76
92573    Lombard test                             CH      D
92575    Sensorineural acuity test                        X      0364            0.4627       $28.44                7.06          $5.69
92576    Synthetic sentence test                          X      0364            0.4627       $28.44                7.06          $5.69
92577    Stenger test, speech                             X      0366            1.8511      $113.78               26.14         $22.76
92579    Visual audiometry (vra)                          X      0365            1.2419       $76.34               18.52         $15.27
92582    Conditioning play audiometry                     X      0365            1.2419       $76.34             $18.52          $15.27
92583    Select picture audiometry                        X      0364            0.4627       $28.44              $7.06           $5.69
92584    Electrocochleography                             X      0660            1.4461       $88.89             $28.06          $17.78
92585    Auditor evoke potent, compre                     S      0216            2.7199      $167.19                             $33.44
92586    Auditor evoke potent, limit                      S      0218            1.1872       $72.97                             $14.59
92587    Evoked auditory test                             X      0363            0.8525       $52.40             $17.44          $10.48
92588    Evoked auditory test                             X      0660            1.4461         88.89              28.06           17.78
92590    Hearing aid exam, one ear                        E
92591    Hearing aid exam, both ears                      E
92592    Hearing aid check, one ear                       E
92593    Hearing aid check, both ears                     E
92594    Electro hearng aid test, one                     E
92595    Electro hearng aid tst, both                     E
92596    Ear protector evaluation                         X      0364            0.4627         28.44               7.06              5.69
92597    Oral speech device eval                          A
92601    Cochlear implt f/up exam < 7                     X      0366            1.8511        113.78             26.14              22.76
92602    Reprogram cochlear implt < 7                     X      0366            1.8511        113.78             26.14              22.76
92603    Cochlear implt f/up exam 7 >                     X      0366            1.8511        113.78             26.14              22.76
92604    Reprogram cochlear implt 7 >                     X      0366            1.8511        113.78             26.14              22.76
92605    Eval for nonspeech device rx                     A
92606    Non-speech device service                        A
92607    Ex for speech device rx, 1hr                     A
92608    Ex for speech device rx addl                     A
92609    Use of speech device service                     A
92610    Evaluate swallowing function                     A
92611    Motion fluoroscopy/swallow                       A
92612    Endoscopy swallow tst (fees)                     A
92613    Endoscopy swallow tst (fees)                     B
92614    Laryngoscopic sensory test                       A
92615    Eval laryngoscopy sense tst                      E
92616    Fees w/laryngeal sense test                      A
92617    Interprt fees/laryngeal test                     E
92620    Auditory function, 60 min                        X      0365            1.2419       $76.34             $18.52          $15.27
92621    Auditory function, + 15 min                      N
92625    Tinnitus assessment                              X      0365            1.2419       $76.34             $18.52          $15.27
92626    Eval aud rehab status                            X      0365            1.2419       $76.34             $18.52          $15.27
92627    Eval aud status rehab add-on                     N
92630    Aud rehab pre-ling hear loss                     E
92633    Aud rehab postling hear loss                     E
92640    Aud brainstem implt programg             NI      X      0365
                                                                   Milliman 1.2419              76.34             18.52              15.27
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                       National   Minimum
HCPCS/                                                                         Relative               Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate    Copayment Copayment
92700    Ent procedure/service                            X      0364            0.4627     28.44            7.06       5.69
92950    Heart/lung resuscitation cpr                     S      0094            2.4233    148.96           46.29      29.79
92953    Temporary external pacing                        S      0094            2.4233    148.96           46.29      29.79
92960    Cardioversion electric, ext                      S      0679            5.5233    339.51            95.3       67.9
92961    Cardioversion, electric, int                     S      0679            5.5233    339.51            95.3       67.9
92970    Cardioassist, internal                           C
92971    Cardioassist, external                           C
92973    Percut coronary thrombectomy                     T      0088           37.7391    2319.75            655.22         463.95
92974    Cath place, cardio brachytx                      T      0103           16.2375     998.09            223.63         199.62
92975    Dissolve clot, heart vessel                      C
92977    Dissolve clot, heart vessel                      T      0676            2.0726      127.4                            25.48
92978    Intravasc us, heart add-on                       S      0670           32.2854    1984.52             536.1          396.9
92979    Intravasc us, heart add-on                       S      0416           32.5472    2000.61                           400.12
92980    Insert intracoronary stent                       T      0104           87.7183    5391.87                          1078.37
92981    Insert intracoronary stent                       T      0104           87.7183    5391.87                          1078.37
92982    Coronary artery dilation                         T      0083           58.7904    3613.73                           722.75
92984    Coronary artery dilation                         T      0083           58.7904    3613.73                           722.75
92986    Revision of aortic valve                         T      0083           58.7904    3613.73                           722.75
92987    Revision of mitral valve                         T      0083           58.7904    3613.73                           722.75
92990    Revision of pulmonary valve                      T      0083           58.7904    3613.73                           722.75
92992    Revision of heart chamber                        C
92993    Revision of heart chamber                        C
92995    Coronary atherectomy                             T      0082           72.1982    4437.88            954.62         887.58
92996    Coronary atherectomy add-on                      T      0082           72.1982    4437.88            954.62         887.58
92997    Pul art balloon repr, percut                     T      0081           42.9360    2639.19                           527.84
92998    Pul art balloon repr, percut                     T      0081           42.9360    2639.19                           527.84
93000    Electrocardiogram, complete                      B
93005    Electrocardiogram, tracing                       S      0099            0.3789      23.29                                4.66
93010    Electrocardiogram report                         B
93012    Transmission of ecg                              N
93014    Report on transmitted ecg                        B
93015    Cardiovascular stress test                       B
93016    Cardiovascular stress test                       B
93017    Cardiovascular stress test                       X      0100            2.5336     155.74             41.44             31.15
93018    Cardiovascular stress test                       B
93024    Cardiac drug stress test                         X      0100            2.5336     155.74             41.44             31.15
93025    Microvolt t-wave assess                          X      0100            2.5336     155.74             41.44             31.15
93040    Rhythm ECG with report                           B
93041    Rhythm ECG, tracing                              S      0099            0.3789      23.29                                4.66
93042    Rhythm ECG, report                               B
93224    ECG monitor/report, 24 hrs                       B
93225    ECG monitor/record, 24 hrs                       X      0097            1.0225      62.85             23.79             12.57
93226    ECG monitor/report, 24 hrs                       X      0097            1.0225      62.85             23.79             12.57
93227    ECG monitor/review, 24 hrs                       B
93230    ECG monitor/report, 24 hrs                       B
93231    Ecg monitor/record, 24 hrs                       X      0097            1.0225      62.85             23.79             12.57
93232    ECG monitor/report, 24 hrs                       X      0097            1.0225      62.85             23.79             12.57
93233    ECG monitor/review, 24 hrs                       B
93235    ECG monitor/report, 24 hrs                       B
93236    ECG monitor/report, 24 hrs                       X      0097            1.0225     $62.85             23.79         $12.57
93237    ECG monitor/review, 24 hrs                       B
93268    ECG record/review                                B
93270    ECG recording                                    X        Milliman 1.0225
                                                                 0097                       $62.85             23.79         $12.57
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                    National   Minimum
HCPCS/                                                                         Relative            Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment Copayment
93271    Ecg/monitoring and analysis                      X      0097            1.0225   $62.85         23.79    $12.57
93272    Ecg/review, interpret only                       B
93278    ECG/signal-averaged                              S      0099            0.3789       23.29                                 4.66
93303    Echo transthoracic                               S      0269            3.2154      197.64               75.6             39.53
93304    Echo transthoracic                               S      0697            1.5973       98.18              35.99             19.64
93307    Echo exam of heart                               S      0269            3.2154      197.64               75.6             39.53
93308    Echo exam of heart                               S      0697            1.5973       98.18              35.99             19.64
93312    Echo transesophageal                             S      0270            6.2505      384.21             141.32             76.84
93313    Echo transesophageal                             S      0270            6.2505      384.21             141.32             76.84
93314    Echo transesophageal                             N
93315    Echo transesophageal                             S      0270            6.2505      384.21             141.32             76.84
93316    Echo transesophageal                             S      0270            6.2505      384.21             141.32             76.84
93317    Echo transesophageal                             N
93318    Echo transesophageal intraop                     S      0270            6.2505       384.21          141.32            76.84
93320    Doppler echo exam, heart                 CH      S      0697            1.5973        98.18           35.99            19.64
93321    Doppler echo exam, heart                         S      0697            1.5973        98.18           35.99            19.64
93325    Doppler color flow add-on                        S      0697            1.5973        98.18           35.99            19.64
93350    Echo transthoracic                               S      0269            3.2154       197.64            75.6            39.53
93501    Right heart catheterization                      T      0080           37.0615       2278.1          838.92           455.62
93503    Insert/place heart catheter                      T      0103           16.2375       998.09          223.63           199.62
93505    Biopsy of heart lining                           T      0103           16.2375       998.09          223.63           199.62
93508    Cath placement, angiography                      T      0080           37.0615       2278.1          838.92           455.62
93510    Left heart catheterization                       T      0080           37.0615       2278.1          838.92           455.62
93511    Left heart catheterization                       T      0080           37.0615       2278.1          838.92           455.62
93514    Left heart catheterization                       T      0080           37.0615       2278.1          838.92           455.62
93524    Left heart catheterization                       T      0080           37.0615       2278.1          838.92           455.62
93526    Rt & lT heart catheters                          T      0080           37.0615       2278.1          838.92           455.62
93527    Rt & lT heart catheters                          T      0080           37.0615       2278.1          838.92           455.62
93528    Rt & lT heart catheters                          T      0080           37.0615       2278.1          838.92           455.62
93529    Rt, lt heart catheterization                     T      0080           37.0615   $2,278.10         $838.92          $455.62
93530    Rt heart cath, congenital                        T      0080           37.0615       2278.1          838.92           455.62
93531    R& l heart cath, congenital                      T      0080           37.0615       2278.1          838.92           455.62
93532    R& l heart cath, congenital                      T      0080           37.0615       2278.1          838.92           455.62
93533    R& l heart cath, congenital                      T      0080           37.0615       2278.1          838.92           455.62
93539    Injection, cardiac cath                          N
93540    Injection, cardiac cath                          N
93541    Injection for lung angiogram                     N
93542    Injection for heart x-rays                       N
93543    Injection for heart x-rays                       N
93544    Injection for aortography                        N
93545    Inject for coronary x-rays                       N
93555    Imaging, cardiac cath                            N
93556    Imaging, cardiac cath                            N
93561    Cardiac output measurement                       N
93562    Cardiac output measurement                       N
93571    Heart flow reserve measure                       S      0670     32.2854         $1,984.52              536.1        $396.90
93572    Heart flow reserve measure                       S      0416     32.5472         $2,000.61                           $400.12
93580    Transcath closure of asd                         T      0434     88.0728         $5,413.66                         $1,082.73
93581    Transcath closure of vsd                         T      0434     88.0728         $5,413.66                         $1,082.73
93600    Bundle of His recording                          T      0087     32.8988         $2,022.22                           $404.44
93602    Intra-atrial recording                           T      0087     32.8988         $2,022.22                           $404.44
93603    Right ventricular recording                      T      0087     32.8988           2022.22                             404.44
93609    Map tachycardia, add-on                          T      0087     32.8988
                                                                   Milliman                 2022.22                             404.44
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     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                   Page 137 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
93610    Intra-atrial pacing                              T      0087           32.8988       2022.22                  404.44
93612    Intraventricular pacing                          T      0087           32.8988       2022.22                  404.44
93613    Electrophys map 3d, add-on                       T      0087           32.8988       2022.22                  404.44
93615    Esophageal recording                             T      0087           32.8988       2022.22                  404.44
93616    Esophageal recording                             T      0087           32.8988       2022.22                  404.44
93618    Heart rhythm pacing                              T      0087           32.8988       2022.22                  404.44
93619    Electrophysiology evaluation                     T      0085           34.2808       2107.17       426.25     421.43
93620    Electrophysiology evaluation                     T      0085           34.2808       2107.17       426.25     421.43
93621    Electrophysiology evaluation                     T      0085           34.2808       2107.17       426.25     421.43
93622    Electrophysiology evaluation                     T      0085           34.2808       2107.17       426.25     421.43
93623    Stimulation, pacing heart                        T      0087           32.8988       2022.22                  404.44
93624    Electrophysiologic study                         T      0085           34.2808       2107.17       426.25     421.43
93631    Heart pacing, mapping                            T      0087           32.8988       2022.22                  404.44
93640    Evaluation heart device                  CH      N
93641    Electrophysiology evaluation             CH      N
93642    Electrophysiology evaluation                     S      0084            9.8924       $608.07                           $121.61
93650    Ablate heart dysrhythm focus                     T      0086           47.4931     $2,919.31             812.36        $583.86
93651    Ablate heart dysrhythm focus                     T      0086           47.4931     $2,919.31             812.36        $583.86
93652    Ablate heart dysrhythm focus                     T      0086           47.4931        2919.31            812.36          583.86
93660    Tilt table evaluation                            S      0101            4.2769         262.89            100.24           52.58
93662    Intracardiac ecg (ice)                           S      0670           32.2854        1984.52             536.1           396.9
93668    Peripheral vascular rehab                        E
93701    Bioimpedance, thoracic                           S      0099            0.3789         23.29                                  4.66
93720    Total body plethysmography                       B
93721    Plethysmography tracing                          X      0368            0.9454         58.11              22.77              11.62
93722    Plethysmography report                           B
93724    Analyze pacemaker system                         S      0690            0.3613       $22.21                 8.67          $4.44
93727    Analyze ilr system                               S      0690            0.3613       $22.21                 8.67          $4.44
93731    Analyze pacemaker system                         S      0690            0.3613       $22.21                 8.67          $4.44
93732    Analyze pacemaker system                         S      0690            0.3613       $22.21                 8.67          $4.44
93733    Telephone analy, pacemaker                       S      0690            0.3613       $22.21                 8.67          $4.44
93734    Analyze pacemaker system                         S      0690            0.3613       $22.21               $8.67           $4.44
93735    Analyze pacemaker system                         S      0690            0.3613       $22.21               $8.67           $4.44
93736    Telephonic analy, pacemaker                      S      0690            0.3613       $22.21               $8.67           $4.44
93740    Temperature gradient studies                     X      0368            0.9454       $58.11              $22.77          $11.62
93741    Analyze ht pace device sngl                      S      0689            0.6003       $36.90                               $7.38
93742    Analyze ht pace device sngl                      S      0689            0.6003          36.9                                7.38
93743    Analyze ht pace device dual                      S      0689            0.6003          36.9                                7.38
93744    Analyze ht pace device dual                      S      0689            0.6003          36.9                                7.38
93745    Set-up cardiovert-defibrill                      S      0689            0.6003       $36.90                               $7.38
93760    Cephalic thermogram                              E
93762    Peripheral thermogram                            E
93770    Measure venous pressure                          N
93784    Ambulatory BP monitoring                         E
93786    Ambulatory BP recording                          X      0097            1.0225         62.85              23.79              12.57
93788    Ambulatory BP analysis                           X      0097            1.0225         62.85              23.79              12.57
93790    Review/report BP recording                       B
93797    Cardiac rehab                                    S      0095       0.5748              35.33              13.86               7.07
93798    Cardiac rehab/monitor                            S      0095       0.5748              35.33              13.86               7.07
93799    Cardiovascular procedure                 CH      X      0097       1.0225              62.85              23.79              12.57
93875    Extracranial study                               S      0096       1.5303              94.06              37.62              18.81
93880    Extracranial study                               S      0267       2.4606             151.25               60.5              30.25
93882    Extracranial study                               S        Milliman 2.4606
                                                                 0267                          151.25               60.5              30.25
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 138 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468           2007 CF
                                                                                                       National   Minimum
HCPCS/                                                                         Relative               Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate    Copayment Copayment
93886    Intracranial study                               S      0267            2.4606    151.25            60.5      30.25
93888    Intracranial study                       CH      S      0265            0.9923     60.99           23.63       12.2
93890    Tcd, vasoreactivity study                        S      0266            1.5607     95.93            37.8      19.19
93892    Tcd, emboli detect w/o inj                       S      0266            1.5607     95.93            37.8      19.19
93893    Tcd, emboli detect w/inj                         S      0266            1.5607     95.93            37.8      19.19
93922    Extremity study                                  S      0096            1.5303     94.06           37.62      18.81
93923    Extremity study                                  S      0096            1.5303     94.06           37.62      18.81
93924    Extremity study                                  S      0096            1.5303     94.06           37.62      18.81
93925    Lower extremity study                            S      0267            2.4606    151.25            60.5      30.25
93926    Lower extremity study                            S      0266            1.5607     95.93            37.8      19.19
93930    Upper extremity study                            S      0267            2.4606    151.25            60.5      30.25
93931    Upper extremity study                            S      0266            1.5607     95.93            37.8      19.19
93965    Extremity study                                  S      0096            1.5303     94.06           37.62      18.81
93970    Extremity study                                  S      0267            2.4606    151.25            60.5      30.25
93971    Extremity study                                  S      0266            1.5607     95.93            37.8      19.19
93975    Vascular study                                   S      0267            2.4606    151.25            60.5      30.25
93976    Vascular study                                   S      0267            2.4606    151.25            60.5      30.25
93978    Vascular study                                   S      0266            1.5607     95.93            37.8      19.19
93979    Vascular study                                   S      0266            1.5607     95.93            37.8      19.19
93980    Penile vascular study                            S      0267            2.4606    151.25            60.5      30.25
93981    Penile vascular study                            S      0266            1.5607     95.93            37.8      19.19
93990    Doppler flow testing                             S      0266            1.5607     95.93            37.8      19.19
94002    Vent mgmt inpat, init day                NI      S      0079            2.6116    160.53                      32.11
94003    Vent mgmt inpat, subq day                NI      S      0079            2.6116    160.53                      32.11
94004    Vent mgmt nf per day                     NI      B
94005    Home vent mgmt supervision               NI      E
94010    Breathing capacity test                          X      0368            0.9454      58.11            22.77             11.62
94014    Patient recorded spirometry                      X      0367            0.6277      38.58            14.68              7.72
94015    Patient recorded spirometry                      X      0367            0.6277      38.58            14.68              7.72
94016    Review patient spirometry                        A
94060    Evaluation of wheezing                           X      0368            0.9454      58.11            22.77             11.62
94070    Evaluation of wheezing                           X      0369            2.7669     170.08            44.18             34.02
94150    Vital capacity test                              X      0367            0.6277      38.58            14.68              7.72
94200    Lung function test (MBC/MVV)                     X      0367            0.6277      38.58            14.68              7.72
94240    Residual lung capacity                           X      0368            0.9454      58.11            22.77             11.62
94250    Expired gas collection                           X      0367            0.6277      38.58            14.68              7.72
94260    Thoracic gas volume                      CH      X      0368            0.9454      58.11            22.77             11.62
94350    Lung nitrogen washout curve              CH      X      0368            0.9454      58.11            22.77             11.62
94360    Measure airflow resistance                       X      0367            0.6277      38.58            14.68              7.72
94370    Breath airway closing volume                     X      0367            0.6277      38.58            14.68              7.72
94375    Respiratory flow volume loop                     X      0367            0.6277      38.58            14.68              7.72
94400    CO2 breathing response curve                     X      0367            0.6277      38.58            14.68              7.72
94450    Hypoxia response curve                           X      0368            0.9454      58.11            22.77             11.62
94452    Hast w/report                                    X      0368            0.9454      58.11            22.77             11.62
94453    Hast w/oxygen titrate                    CH      X      0367            0.6277      38.58            14.68              7.72
94610    Surfactant admin thru tube               NI      S      0077            0.3527      21.68             7.74              4.34
94620    Pulmonary stress test/simple                     X      0368            0.9454      58.11            22.77             11.62
94621    Pulm stress test/complex                         X      0369            2.7669     170.08            44.18             34.02
94640    Airway inhalation treatment                      S      0077            0.3527      21.68             7.74              4.34
94642    Aerosol inhalation treatment                     S      0078            1.1206      68.88            14.55             13.78
94644    Cbt, 1st hour                            NI      S      0078            1.1206      68.88            14.55             13.78
94645    Cbt, each addl hour                      NI      S      0078            1.1206      68.88            14.55             13.78
94656    Initial ventilator mgmt                  CH      D        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                Page 139 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                         61.468             2007 CF
                                                                                                        National             Minimum
HCPCS/                                                                         Relative                Unadjusted            Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment             Copayment
94657    Continued ventilator mgmt                CH      D
94660    Pos airway pressure, CPAP                        S      0068            1.5353          94.37             29.48               18.87
94662    Neg press ventilation, cnp                       S      0079            2.6116         160.53                                 32.11
94664    Evaluate pt use of inhaler                       S      0077            0.3527        $21.68                7.74             $4.34
94667    Chest wall manipulation                          S      0077            0.3527          21.68               7.74               4.34
94668    Chest wall manipulation                          S      0077            0.3527          21.68               7.74               4.34
94680    Exhaled air analysis, o2                         X      0367            0.6277          38.58              14.68               7.72
94681    Exhaled air analysis, o2/co2                     X      0368            0.9454          58.11              22.77              11.62
94690    Exhaled air analysis                     CH      X      0367            0.6277        $38.58             $14.68              $7.72
94720    Monoxide diffusing capacity                      X      0368            0.9454          58.11              22.77              11.62
94725    Membrane diffusion capacity                      X      0368            0.9454          58.11              22.77              11.62
94750    Pulmonary compliance study               CH      X      0367            0.6277          38.58              14.68               7.72
94760    Measure blood oxygen level                       N
94761    Measure blood oxygen level                       N
94762    Measure blood oxygen level               CH      Q      0443            1.0409         63.98              25.59               12.8
94770    Exhaled carbon dioxide test                      X      0367            0.6277         38.58              14.68               7.72
94772    Breath recording, infant                         X      0369            2.7669        170.08              44.18              34.02
94774    Ped home apnea rec, compl                NI      B
94775    Ped home apnea rec, hk-up                NI      X      0097            1.0225         62.85              23.79              12.57
94776    Ped home apnea rec, downld               NI      X      0097            1.0225         62.85              23.79              12.57
94777    Ped home apnea rec, report               NI      B
94799    Pulmonary service/procedure                      X      0367            0.6277         38.58              14.68               7.72
95004    Percut allergy skin tests                        X      0381            0.2688         16.52                                   3.3
95010    Percut allergy titrate test                      X      0381            0.2688         16.52                                   3.3
95012    Exhaled nitric oxide meas                NI      X      0367            0.6277         38.58              14.68               7.72
95015    Id allergy titrate-drug/bug                      X      0381            0.2688         16.52                                   3.3
95024    Id allergy test, drug/bug                        X      0381            0.2688         16.52                                   3.3
95027    Id allergy titrate-airborne                      X      0381            0.2688         16.52                                   3.3
95028    Id allergy test-delayed type                     X      0381            0.2688         16.52                                   3.3
95044    Allergy patch tests                              X      0381            0.2688         16.52                                   3.3
95052    Photo patch test                                 X      0381            0.2688         16.52                                   3.3
95056    Photosensitivity tests                           X      0370            1.0270         63.13                                 12.63
95060    Eye allergy tests                                X      0370            1.0270         63.13                                 12.63
95065    Nose allergy test                                X      0381            0.2688         16.52                                   3.3
95070    Bronchial allergy tests                          X      0369            2.7669        170.08              44.18              34.02
95071    Bronchial allergy tests                          X      0369            2.7669        170.08              44.18              34.02
95075    Ingestion challenge test                         X      0361            3.8887        239.03              83.23              47.81
95078    Provocative testing                      CH      D
95115    Immunotherapy, one injection             CH      S      0436            0.1809         11.12                                  2.22
95117    Immunotherapy injections                 CH      S      0437            0.3945         24.25                                  4.85
95120    Immunotherapy, one injection                     B
95125    Immunotherapy, many antigens                     B
95130    Immunotherapy, insect venom                      B
95131    Immunotherapy, insect venoms                     B
95132    Immunotherapy, insect venoms                     B
95133    Immunotherapy, insect venoms                     B
95134    Immunotherapy, insect venoms                     B
95144    Antigen therapy services                 CH      S      0437       0.3945              24.25                                  4.85
95145    Antigen therapy services                 CH      S      0437       0.3945              24.25                                  4.85
95146    Antigen therapy services                 CH      S      0437       0.3945              24.25                                  4.85
95147    Antigen therapy services                 CH      S      0437       0.3945              24.25                                  4.85
95148    Antigen therapy services                 CH      S      0437       0.3945              24.25                                  4.85
95149    Antigen therapy services                 CH      S        Milliman 0.3945
                                                                 0437                           24.25                                  4.85
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                                      Page 140 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
95165    Antigen therapy services                 CH      S      0437            0.3945         24.25                             4.85
95170    Antigen therapy services                 CH      S      0437            0.3945         24.25                             4.85
95180    Rapid desensitization                            X      0370            1.0270         63.13                            12.63
95199    Allergy immunology services              CH      X      0381            0.2688         16.52                              3.3
95250    Glucose monitoring, cont                         X      0421            1.6270        100.01                               20
95251    Gluc monitor, cont, phys i&r                     B
95805    Multiple sleep latency test                      S      0209           11.2463        691.29            268.73         138.26
95806    Sleep study, unattended                          S      0213            2.2755        139.87             53.58          27.97
95807    Sleep study, attended                            S      0209           11.2463        691.29            268.73         138.26
95808    Polysomnography, 1-3                             S      0209           11.2463        691.29            268.73         138.26
95810    Polysomnography, 4 or more                       S      0209           11.2463        691.29            268.73         138.26
95811    Polysomnography w/cpap                           S      0209           11.2463        691.29            268.73         138.26
95812    Eeg, 41-60 minutes                               S      0213            2.2755        139.87             53.58          27.97
95813    Eeg, over 1 hour                                 S      0213            2.2755        139.87             53.58          27.97
95816    Eeg, awake and drowsy                            S      0213            2.2755        139.87             53.58          27.97
95819    Eeg, awake and asleep                            S      0213            2.2755        139.87             53.58          27.97
95822    Eeg, coma or sleep only                          S      0213            2.2755        139.87             53.58          27.97
95824    Eeg, cerebral death only                         S      0214            1.1968         73.56             28.24          14.71
95827    Eeg, all night recording                         S      0213            2.2755        139.87             53.58          27.97
95829    Surgery electrocorticogram                       S      0214            1.1968         73.56             28.24          14.71
95830    Insert electrodes for EEG                        B
95831    Limb muscle testing, manual                      A
95832    Hand muscle testing, manual                      A
95833    Body muscle testing, manual                      A
95834    Body muscle testing, manual                      A
95851    Range of motion measurements                     A
95852    Range of motion measurements                     A
95857    Tensilon test                                    S      0218       1.1872              72.97                               14.59
95860    Muscle test, one limb                            S      0218       1.1872              72.97                               14.59
95861    Muscle test, 2 limbs                             S      0218       1.1872              72.97                               14.59
95863    Muscle test, 3 limbs                             S      0218       1.1872              72.97                               14.59
95864    Muscle test, 4 limbs                             S      0218       1.1872              72.97                               14.59
95865    Muscle test, larynx                              S      0218       1.1872              72.97                               14.59
95866    Muscle test, hemidiaphragm                       S      0218       1.1872              72.97                               14.59
95867    Muscle test cran nerv unilat                     S      0218       1.1872              72.97                               14.59
95868    Muscle test cran nerve bilat                     S      0218       1.1872              72.97                               14.59
95869    Muscle test, thor paraspinal                     S      0215       0.5741              35.29                                7.06
95870    Muscle test, nonparaspinal                       S      0215       0.5741              35.29                                7.06
95872    Muscle test, one fiber                           S      0218       1.1872              72.97                               14.59
95873    Guide nerv destr, elec stim                      S      0215       0.5741              35.29                                7.06
95874    Guide nerv destr, needle emg                     S      0215       0.5741              35.29                                7.06
95875    Limb exercise test                               S      0215       0.5741              35.29                                7.06
95900    Motor nerve conduction test                      S      0215       0.5741              35.29                                7.06
95903    Motor nerve conduction test                      S      0215       0.5741              35.29                                7.06
95904    Sense nerve conduction test                      S      0215       0.5741              35.29                                7.06
95920    Intraop nerve test add-on                        S      0216       2.7199             167.19                               33.44
95921    Autonomic nerv function test             CH      S      0215       0.5741              35.29                                7.06
95922    Autonomic nerv function test             CH      S      0215       0.5741              35.29                                7.06
95923    Autonomic nerv function test             CH      S      0215       0.5741              35.29                                7.06
95925    Somatosensory testing                            S      0216       2.7199             167.19                               33.44
95926    Somatosensory testing                            S      0216       2.7199             167.19                               33.44
95927    Somatosensory testing                            S      0216       2.7199             167.19                               33.44
95928    Cmotor evoked, uppr limbs                        S        Milliman 1.1872
                                                                 0218                           72.97                               14.59
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment Copayment
95929    Cmotor evoked, lwr limbs                         S      0218            1.1872         72.97                   14.59
95930    Visual evoked potential test                     S      0216            2.7199        167.19                   33.44
95933    Blink reflex test                                S      0215            0.5741         35.29                    7.06
95934    H-reflex test                                    S      0215            0.5741         35.29                    7.06
95936    H-reflex test                                    S      0215            0.5741         35.29                    7.06
95937    Neuromuscular junction test              CH      S      0215            0.5741         35.29                    7.06
95950    Ambulatory eeg monitoring                        S      0209           11.2463        691.29       268.73     138.26
95951    EEG monitoring/videorecord                       S      0209           11.2463        691.29       268.73     138.26
95953    EEG monitoring/computer                          S      0209           11.2463        691.29       268.73     138.26
95954    EEG monitoring/giving drugs                      S      0214            1.1968         73.56        28.24      14.71
95955    EEG during surgery                               S      0213            2.2755        139.87        53.58      27.97
95956    Eeg monitoring, cable/radio                      S      0209           11.2463        691.29       268.73     138.26
95957    EEG digital analysis                             S      0214            1.1968         73.56        28.24      14.71
95958    EEG monitoring/function test                     S      0213            2.2755        139.87        53.58      27.97
95961    Electrode stimulation, brain                     S      0216            2.7199        167.19                   33.44
95962    Electrode stim, brain add-on                     S      0216            2.7199        167.19                   33.44
95965    Meg, spontaneous                         CH      S      0038           53.5161       3289.53                  657.91
95966    Meg, evoked, single                      CH      S      0209           11.2463        691.29       268.73     138.26
95967    Meg, evoked, each addÆl                  CH      S      0209           11.2463        691.29       268.73     138.26
95970    Analyze neurostim, no prog                       S      0218            1.1872         72.97                   14.59
95971    Analyze neurostim, simple                        S      0692            1.9323        118.77        30.16      23.75
95972    Analyze neurostim, complex                       S      0692            1.9323        118.77        30.16      23.75
95973    Analyze neurostim, complex               CH      S      0663            1.1067         68.03        17.45      13.61
95974    Cranial neurostim, complex                       S      0692            1.9323        118.77        30.16      23.75
95975    Cranial neurostim, complex                       S      0692            1.9323        118.77        30.16      23.75
95978    Analyze neurostim brain/1h                       S      0692            1.9323        118.77        30.16      23.75
95979    Analyz neurostim brain addon             CH      S      0663            1.1067         68.03        17.45      13.61
95990    Spin/brain pump refil & main                     T      0125            2.2041        135.48                    27.1
95991    Spin/brain pump refil & main                     T      0125            2.2041        135.48                    27.1
95999    Neurological procedure                           S      0215            0.5741         35.29                    7.06
96000    Motion analysis, video/3d                        S      0216            2.7199        167.19                   33.44
96001    Motion test w/ft press meas                      S      0216            2.7199        167.19                   33.44
96002    Dynamic surface emg                              S      0218            1.1872         72.97                   14.59
96003    Dynamic fine wire emg                            S      0215            0.5741         35.29                    7.06
96004    Phys review of motion tests                      B
96020    Functional brain mapping                 NI      X      0373            1.7682        108.69                              21.74
96040    Genetic counseling, 30 min               NI      E
96101    Psycho testing by psych/phys                     X      0373            1.7682        108.69                              21.74
96102    Psycho testing by technician                     X      0382            2.8460        174.94            69.97             34.99
96103    Psycho testing admin by comp                     X      0373            1.7682        108.69                              21.74
96105    Assessment of aphasia                            A
96110    Developmental test, lim                          X      0373            1.7682        108.69                              21.74
96111    Developmental test, extend                       X      0373            1.7682        108.69                              21.74
96116    Neurobehavioral status exam                      X      0373            1.7682        108.69                              21.74
96118    Neuropsych tst by psych/phys                     X      0373            1.7682        108.69                              21.74
96119    Neuropsych testing by tec                        X      0382            2.8460        174.94            69.97             34.99
96120    Neuropsych tst admin w/comp                      X      0373            1.7682        108.69                              21.74
96150    Assess hlth/behave, init                         S      0432            0.6072         37.32                               7.46
96151    Assess hlth/behave, subseq                       S      0432            0.6072         37.32                               7.46
96152    Intervene hlth/behave, indiv                     S      0432            0.6072         37.32                               7.46
96153    Intervene hlth/behave, group                     S      0432            0.6072         37.32                               7.46
96154    Interv hlth/behav, fam w/pt                      S      0432            0.6072         37.32                               7.46
96155    Interv hlth/behav fam no pt                      E        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468          2007 CF
                                                                                                        National   Minimum
HCPCS/                                                                         Relative                Unadjusted Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment Copayment
96401    Chemo, anti-neopl, sq/im                 CH      S      0438            0.7942         48.82                    9.76
96402    Chemo hormon antineopl sq/im             CH      S      0438            0.7942         48.82                    9.76
96405    Chemo intralesional, up to 7             CH      S      0438            0.7942         48.82                    9.76
96406    Chemo intralesional over 7               CH      S      0438            0.7942         48.82                    9.76
96409    Chemo, iv push, sngl drug                CH      S      0439            1.5848         97.41                   19.48
96411    Chemo, iv push, addl drug                CH      S      0439            1.5848         97.41                   19.48
96413    Chemo, iv infusion, 1 hr                 CH      S      0441            2.4851        152.75                   30.55
96415    Chemo, iv infusion, addl hr              CH      S      0438            0.7942         48.82                    9.76
96416    Chemo prolong infuse w/pump              CH      S      0441            2.4851        152.75                   30.55
96417    Chemo iv infus each addl seq             CH      S      0438            0.7942         48.82                    9.76
96420    Chemo, ia, push tecnique                 CH      S      0439            1.5848         97.41                   19.48
96422    Chemo ia infusion up to 1 hr             CH      S      0441            2.4851        152.75                   30.55
96423    Chemo ia infuse each addl hr             CH      S      0438            0.7942         48.82                    9.76
96425    Chemotherapy,infusion method             CH      S      0441            2.4851        152.75                   30.55
96440    Chemotherapy, intracavitary              CH      S      0441            2.4851        152.75                   30.55
96445    Chemotherapy, intracavitary              CH      S      0441            2.4851        152.75                   30.55
96450    Chemotherapy, into CNS                   CH      S      0441            2.4851        152.75                   30.55
96521    Refill/maint, portable pump              CH      S      0440            1.8090         111.2                   22.24
96522    Refill/maint pump/resvr syst             CH      S      0440            1.8090         111.2                   22.24
96523    Irrig drug delivery device               CH      Q      0624            0.5145         31.63        12.65       6.33
96542    Chemotherapy injection                   CH      S      0438            0.7942         48.82                    9.76
96549    Chemotherapy, unspecified                CH      S      0436            0.1809         11.12                    2.22
96567    Photodynamic tx, skin                            T      0016            2.6749        164.42                   32.88
96570    Photodynamic tx, 30 min                          T      0015            1.6241         99.83        20.13      19.97
96571    Photodynamic tx, addl 15 min                     T      0015            1.6241         99.83        20.13      19.97
96900    Ultraviolet light therapy                        S      0001            0.4914         30.21            7       6.04
96902    Trichogram                                       N
96904    Whole body photography                   NI      N
96910    Photochemotherapy with UV-B                      S      0001            0.4914         30.21              7               6.04
96912    Photochemotherapy with UV-A                      S      0001            0.4914         30.21              7               6.04
96913    Photochemotherapy, UV-A or B                     S      0683            2.6734        164.33                             32.87
96920    Laser tx, skin < 250 sq cm                       T      0013            1.0918         67.11                             13.42
96921    Laser tx, skin 250-500 sq cm                     T      0013            1.0918         67.11                             13.42
96922    Laser tx, skin > 500 sq cm                       T      0013            1.0918         67.11                             13.42
96999    Dermatological procedure                         T      0010            0.4760         29.26            8.02              5.85
97001    Pt evaluation                                    A
97002    Pt re-evaluation                                 A
97003    Ot evaluation                                    A
97004    Ot re-evaluation                                 A
97005    Athletic train eval                              E
97006    Athletic train reeval                            E
97010    Hot or cold packs therapy                        A
97012    Mechanical traction therapy                      A
97014    Electric stimulation therapy                     E
97016    Vasopneumatic device therapy                     A
97018    Paraffin bath therapy                            A
97022    Whirlpool therapy                                A
97024    Diathermy eg, microwave                          A
97026    Infrared therapy                                 A
97028    Ultraviolet therapy                              A
97032    Electrical stimulation                           A
97033    Electric current therapy                         A
97034    Contrast bath therapy                            A        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
97035    Ultrasound therapy                               A
97036    Hydrotherapy                                     A
97039    Physical therapy treatment                       A
97110    Therapeutic exercises                            A
97112    Neuromuscular reeducation                        A
97113    Aquatic therapy/exercises                        A
97116    Gait training therapy                            A
97124    Massage therapy                                  A
97139    Physical medicine procedure                      A
97140    Manual therapy                                   A
97150    Group therapeutic procedures                     A
97530    Therapeutic activities                           A
97532    Cognitive skills development                     A
97533    Sensory integration                              A
97535    Self care mngment training                       A
97537    Community/work reintegration                     A
97542    Wheelchair mngment training                      A
97545    Work hardening                                   A
97546    Work hardening add-on                            A
97597    Active wound care/20 cm or <                     T      0012            0.8432         51.83            11.18             10.37
97598    Active wound care > 20 cm                        T      0013            1.0918         67.11                              13.42
97602    Wound(s) care non-selective                      X      0340            0.6102         37.51                                7.5
97605    Neg press wound tx, < 50 cm                      T      0012            0.8432         51.83            11.18             10.37
97606    Neg press wound tx, > 50 cm                      T      0013            1.0918         67.11                              13.42
97750    Physical performance test                        A
97755    Assistive technology assess                      A
97760    Orthotic mgmt and training                       A
97761    Prosthetic training                              A
97762    C/o for orthotic/prosth use                      A
97799    Physical medicine procedure                      A
97802    Medical nutrition, indiv, in                     A
97803    Med nutrition, indiv, subseq                     A
97804    Medical nutrition, group                         A
97810    Acupunct w/o stimul 15 min                       E
97811    Acupunct w/o stimul addl 15m                     E
97813    Acupunct w/stimul 15 min                         E
97814    Acupunct w/stimul addl 15m                       E
98925    Osteopathic manipulation                         S      0060            0.4657         28.63                               5.73
98926    Osteopathic manipulation                         S      0060            0.4657         28.63                               5.73
98927    Osteopathic manipulation                         S      0060            0.4657         28.63                               5.73
98928    Osteopathic manipulation                         S      0060            0.4657         28.63                               5.73
98929    Osteopathic manipulation                         S      0060            0.4657         28.63                               5.73
98940    Chiropractic manipulation                        S      0060            0.4657         28.63                               5.73
98941    Chiropractic manipulation                        S      0060            0.4657         28.63                               5.73
98942    Chiropractic manipulation                        S      0060            0.4657         28.63                               5.73
98943    Chiropractic manipulation                        E
98960    Self-mgmt educ & train, 1 pt                     E
98961    Self-mgmt educ/train, 2-4 pt                     E
98962    Self-mgmt educ/train, 5-8 pt                     E
99000    Specimen handling                                E
99001    Specimen handling                                E
99002    Device handling                                  B
99024    Postop follow-up visit                           B        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468           2007 CF
                                                                                                        National          Minimum
HCPCS/                                                                         Relative                Unadjusted         Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment          Copayment
99026    In-hospital on call service                      E
99027    Out-of-hosp on call service                      E
99050    Medical services after hrs                       B
99051    Med serv, eve/wkend/holiday                      B
99053    Med serv 10pm-8am, 24 hr fac                     B
99056    Med service out of office                        B
99058    Office emergency care                            B
99060    Out of office emerg med serv                     B
99070    Special supplies                                 B
99071    Patient education materials                      B
99075    Medical testimony                                E
99078    Group health education                           N
99080    Special reports or forms                         B
99082    Unusual physician travel                         B
99090    Computer data analysis                           B
99091    Collect/review data from pt                      N
99100    Special anesthesia service                       B
99116    Anesthesia with hypothermia                      B
99135    Special anesthesia procedure                     B
99140    Emergency anesthesia                             B
99143    Mod cs by same phys, < 5 yrs                     N
99144    Mod cs by same phys, 5 yrs +                     N
99145    Mod cs by same phys add-on                       N
99148    Mod cs diff phys < 5 yrs                         N
99149    Mod cs diff phys 5 yrs +                         N
99150    Mod cs diff phys add-on                          N
99170    Anogenital exam, child                           T      0191            0.1468          9.02             2.55               1.8
99172    Ocular function screen                           E
99173    Visual acuity screen                             E
99175    Induction of vomiting                            N
99183    Hyperbaric oxygen therapy                        B
99185    Regional hypothermia                             N
99186    Total body hypothermia                           N
99190    Special pump services                            C
99191    Special pump services                            C
99192    Special pump services                            C
99195    Phlebotomy                                       X      0372            0.5723         35.18            10.09              7.04
99199    Special service/proc/report                      B
99201    Office/outpatient visit, new             CH      V      0604            0.8242         50.66                              10.13
99202    Office/outpatient visit, new             CH      V      0605            0.9840         60.48                               12.1
99203    Office/outpatient visit, new             CH      V      0606            1.3646         83.88                              16.78
99204    Office/outpatient visit, new             CH      V      0607            1.7096        105.09                              21.02
99205    Office/outpatient visit, new             CH      V      0608            2.1794        133.96                              26.79
99211    Office/outpatient visit, est             CH      V      0604            0.8242         50.66                              10.13
99212    Office/outpatient visit, est             CH      V      0605            0.9840         60.48                               12.1
99213    Office/outpatient visit, est             CH      V      0605            0.9840         60.48                               12.1
99214    Office/outpatient visit, est             CH      V      0606            1.3646         83.88                              16.78
99215    Office/outpatient visit, est             CH      V      0607            1.7096        105.09                              21.02
99217    Observation care discharge                       B
99218    Observation care                                 B
99219    Observation care                                 B
99220    Observation care                                 B
99221    Initial hospital care                            B        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment           Copayment
99222    Initial hospital care                            B
99223    Initial hospital care                            B
99231    Subsequent hospital care                         B
99232    Subsequent hospital care                         B
99233    Subsequent hospital care                         B
99234    Observ/hosp same date                            B
99235    Observ/hosp same date                            B
99236    Observ/hosp same date                            B
99238    Hospital discharge day                           B
99239    Hospital discharge day                           B
99241    Office consultation                      CH      V      0604            0.8242         50.66                               10.13
99242    Office consultation                      CH      V      0605            0.9840         60.48                                12.1
99243    Office consultation                      CH      V      0605            0.9840         60.48                                12.1
99244    Office consultation                      CH      V      0606            1.3646         83.88                               16.78
99245    Office consultation                      CH      V      0607            1.7096        105.09                               21.02
99251    Inpatient consultation                           C
99252    Inpatient consultation                           C
99253    Inpatient consultation                           C
99254    Inpatient consultation                           C
99255    Inpatient consultation                           C
99281    Emergency dept visit                     CH      V      0609            0.8136         50.01              12.7                10
99282    Emergency dept visit                     CH      V      0613            1.3497         82.96             21.06             16.59
99283    Emergency dept visit                     CH      V      0614            2.1150           130              34.5                26
99284    Emergency dept visit                     CH      V      0615            3.4163        209.99             48.49                42
99285    Emergency dept visit                     CH      V      0616            5.2915        325.26             75.11             65.05
99288    Direct advanced life support                     B
99289    Ped crit care transport                          N
99290    Ped crit care transport addl                     N
99291    Critical care, first hour                CH      S      0617            6.5894        405.04            111.59             81.01
99292    Critical care, add'l 30 min                      N
99293    Ped critical care, initial                       C
99294    Ped critical care, subseq                        C
99295    Neonate crit care, initial                       C
99296    Neonate critical care subseq                     C
99298    Ic for lbw infant < 1500 gm                      C
99299    Ic, lbw infant 1500-2500 gm                      C
99300    Ic, infant pbw 2501-5000 gm                      N
99304    Nursing facility care, init                      B
99305    Nursing facility care, init                      B
99306    Nursing facility care, init                      B
99307    Nursing fac care, subseq                         B
99308    Nursing fac care, subseq                         B
99309    Nursing fac care, subseq                         B
99310    Nursing fac care, subseq                         B
99315    Nursing fac discharge day                        B
99316    Nursing fac discharge day                        B
99318    Annual nursing fac assessmnt                     B
99324    Domicil/r-home visit new pat                     B
99325    Domicil/r-home visit new pat                     B
99326    Domicil/r-home visit new pat                     B
99327    Domicil/r-home visit new pat                     B
99328    Domicil/r-home visit new pat                     B
99334    Domicil/r-home visit est pat                     B        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
99335    Domicil/r-home visit est pat                     B
99336    Domicil/r-home visit est pat                     B
99337    Domicil/r-home visit est pat                     B
99339    Domicil/r-home care supervis                     B
99340    Domicil/r-home care supervis                     B
99341    Home visit, new patient                          B
99342    Home visit, new patient                          B
99343    Home visit, new patient                          B
99344    Home visit, new patient                          B
99345    Home visit, new patient                          B
99347    Home visit, est patient                          B
99348    Home visit, est patient                          B
99349    Home visit, est patient                          B
99350    Home visit, est patient                          B
99354    Prolonged service, office                        N
99355    Prolonged service, office                        N
99356    Prolonged service, inpatient                     C
99357    Prolonged service, inpatient                     C
99358    Prolonged serv, w/o contact                      N
99359    Prolonged serv, w/o contact                      N
99360    Physician standby services                       B
99361    Physician/team conference                        N
99362    Physician/team conference                        N
99363    Anticoag mgmt, init                      NI      E
99364    Anticoag mgmt, subseq                    NI      E
99371    Physician phone consultation                     B
99372    Physician phone consultation                     B
99373    Physician phone consultation                     B
99374    Home health care supervision                     B
99375    Home health care supervision                     E
99377    Hospice care supervision                         B
99378    Hospice care supervision                         E
99379    Nursing fac care supervision                     B
99380    Nursing fac care supervision                     B
99381    Init pm e/m, new pat, inf                        E
99382    Init pm e/m, new pat 1-4 yrs                     E
99383    Prev visit, new, age 5-11                        E
99384    Prev visit, new, age 12-17                       E
99385    Prev visit, new, age 18-39                       E
99386    Prev visit, new, age 40-64                       E
99387    Init pm e/m, new pat 65+ yrs                     E
99391    Per pm reeval, est pat, inf                      E
99392    Prev visit, est, age 1-4                         E
99393    Prev visit, est, age 5-11                        E
99394    Prev visit, est, age 12-17                       E
99395    Prev visit, est, age 18-39                       E
99396    Prev visit, est, age 40-64                       E
99397    Per pm reeval est pat 65+ yr                     E
99401    Preventive counseling, indiv                     E
99402    Preventive counseling, indiv                     E
99403    Preventive counseling, indiv                     E
99404    Preventive counseling, indiv                     E
99411    Preventive counseling, group                     E        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment           Copayment
99412    Preventive counseling, group                     E
99420    Health risk assessment test                      E
99429    Unlisted preventive service                      E
99431    Initial care, normal newborn             CH      V      0605            0.9840         60.48                                12.1
99432    Newborn care, not in hosp                        N
99433    Normal newborn care/hospital                     C
99435    Newborn discharge day hosp                       B
99436    Attendance, birth                                N
99440    Newborn resuscitation                            S      0094            2.4233        148.96             46.29             29.79
99450    Basic life disability exam                       E
99455    Work related disability exam                     B
99456    Disability examination                           B
99499    Unlisted e&m service                             B
99500    Home visit, prenatal                             E
99501    Home visit, postnatal                            E
99502    Home visit, nb care                              E
99503    Home visit, resp therapy                         E
99504    Home visit mech ventilator                       E
99505    Home visit, stoma care                           E
99506    Home visit, im injection                         E
99507    Home visit, cath maintain                        E
99509    Home visit day life activity                     E
99510    Home visit, sing/m/fam couns                     E
99511    Home visit, fecal/enema mgmt                     E
99512    Home visit for hemodialysis                      E
99600    Home visit nos                                   E
99601    Home infusion/visit, 2 hrs                       E
99602    Home infusion, each addtl hr                     E
0001F    Heart failure composite                          M
0003T    Cervicography                            CH      D
0005F    Osteoarthritis composite                         M
0008T    Upper gi endoscopy w/suture              CH      D
0012F    Cap bacterial assess                     NI      M
0016T    Thermotx choroid vasc lesion                     T      0235            3.9333        241.77             58.93             48.35
0017T    Photocoagulat macular drusen                     T      0235            3.9333        241.77             58.93             48.35
0018T    Transcranial magnetic stimul             CH      D
0019T    Extracorp shock wv tx,ms nos                     A
0021T    Fetal oximetry, trnsvag/cerv             CH      D
0024T    Transcath cardiac reduction                      C
0026T    Measure remnant lipoproteins                     A
0027T    Endoscopic epidural lysis                        T      0220           17.8499        1097.2                           219.44
0028T    Dexa body composition study                      N
0029T    Magnetic tx for incontinence                     A
0030T    Antiprothrombin antibody                         A
0031T    Speculoscopy                                     N
0032T    Speculoscopy w/direct sample                     N
0041T    Detect ur infect agnt w/cpas                     A
0042T    Ct perfusion w/contrast, cbf                     N
0043T    Co expired gas analysis                          A
0044T    Whole body photography                   CH      D
0045T    Whole body photography                   CH      D
0046T    Cath lavage, mammary duct(s)                     T      0021     15.1024              928.31            219.48         185.66
0047T    Cath lavage, mammary duct(s)                     T      0021     15.1024
                                                                   Milliman                    928.31            219.48         185.66
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468            2007 CF
                                                                                                        National           Minimum
HCPCS/                                                                         Relative                Unadjusted          Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment           Copayment
0048T    Implant ventricular device                       C
0049T    External circulation assist                      C
0050T    Removal circulation assist                       C
0051T    Implant total heart system                       C
0052T    Replace component heart syst                     C
0053T    Replace component heart syst                     C
0054T    Bone surgery using computer                      S      0302            4.9138        302.04            105.94             60.41
0055T    Bone surgery using computer                      S      0302            4.9138        302.04            105.94             60.41
0056T    Bone surgery using computer                      S      0302            4.9138        302.04            105.94             60.41
0058T    Cryopreservation, ovary tiss                     X      0348            0.8321         51.15                               10.23
0059T    Cryopreservation, oocyte                         X      0348            0.8321         51.15                               10.23
0060T    Electrical impedance scan                        B
0061T    Destruction of tumor, breast                     B
0062T    Rep intradisc annulus;1 lev                      T      0050           25.1296       1544.67                           308.93
0063T    Rep intradisc annulus;>1lev                      T      0050           25.1296       1544.67                           308.93
0064T    Spectroscop eval expired gas                     X      0367            0.6277         38.58             14.68           7.72
0065T    Ocular photoscreen bilat                         E
0066T    Ct colonography;screen                           E
0067T    Ct colonography;dx                               S      0333            4.8405        297.54            119.01             59.51
0068T    Interp/rept heart sound                          B
0069T    Analysis only heart sound                        N
0070T    Interp only heart sound                          B
0071T    U/s leiomyomata ablate <200                      T      0195           28.5095       1752.42             483.8         350.48
0072T    U/s leiomyomata ablate >200                      T      0202           42.9896       2642.48             981.5          528.5
0073T    Delivery, comp imrt                              S      0412            5.4731        336.42                            67.28
0074T    Online physician e/m                             E
0075T    Perq stent/chest vert art                        C
0076T    S&i stent/chest vert art                         C
0077T    Cereb therm perfusion probe                      C
0078T    Endovasc aort repr w/device                      C
0079T    Endovasc visc extnsn repr                        C
0080T    Endovasc aort repr rad s&i                       C
0081T    Endovasc visc extnsn s&i                         C
0082T    Stereotactic rad delivery                CH      D
0083T    Stereotactic rad tx mngmt                CH      D
0084T    Temp prostate urethral stent                     T      0164            2.1393         131.5                                26.3
0085T    Breath test heart reject                         X      0340            0.6102         37.51                                 7.5
0086T    Lventricle fill pressure                         N
0087T    Sperm eval hyaluronan                            X      0348            0.8321         51.15                            10.23
0088T    Rf tongue base vol reduxn                        T      0253           16.4266       1009.71            282.29         201.94
0089T    Actigraphy testing, 3-day                        S      0218            1.1872         72.97                            14.59
0090T    Cervical artific disc                    CH      E
0091T    Lumbar artific disc                      CH      D
0092T    Artific disc addl                                C
0093T    Cervical artific diskectomy                      C
0094T    Lumbar artific diskectomy                CH      D
0095T    Artific diskectomy addl                          C
0096T    Rev cervical artific disc                        C
0097T    Rev lumbar artific disc                  CH      D
0098T    Rev artific disc addl                            C
0099T    Implant corneal ring                             T      0233     15.2259              935.91            266.33         187.18
0100T    Prosth retina receive&gen                        T      0672     37.4290             2300.69                           460.14
0101T    Extracorp shockwv tx,hi enrg             CH      T      0050     25.1296
                                                                   Milliman                   1544.67                           308.93
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                       61.468            2007 CF
                                                                                                    National              Minimum
HCPCS/                                                                         Relative            Unadjusted             Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment              Copayment
0102T    Extracorp shockwv tx,anesth              CH      T      0050           25.1296   1544.67                             308.93
0103T    Holotranscobalamin                               A
0104T    At rest cardio gas rebreathe                     A
0105T    Exerc cardio gas rebreathe                       A
0106T    Touch quant sensory test                         X      0341            0.0914        5.62               2.24              1.12
0107T    Vibrate quant sensory test                       X      0341            0.0914        5.62               2.24              1.12
0108T    Cool quant sensory test                          X      0341            0.0914        5.62               2.24              1.12
0109T    Heat quant sensory test                          X      0341            0.0914        5.62               2.24              1.12
0110T    Nos quant sensory test                           X      0341            0.0914        5.62               2.24              1.12
0111T    Rbc membranes fatty acids                        A
0115T    Med tx mngmt 15 min                              B
0116T    Med tx mngmt subsqt                              B
0117T    Med tx mngmt addl 15 min                         B
0120T    Fibroadenoma cryoablate, ea              CH      D
0123T    Scleral fistulization                            T      0234           22.9970     1413.58             511.31         282.72
0124T    Conjunctival drug placement                      T      0232            6.0673      372.94              93.43          74.59
0126T    Chd risk imt study                               N
0130T    Chron care drug investigatn                      B
0133T    Esophageal implant injexn                CH      T      0422           25.7552     1583.12             448.81         316.62
0135T    Perq cryoablate renal tumor              CH      T      0423           37.3604     2296.47                            459.29
0137T    Prostate saturation sampling                     T      0184            5.6262      345.83              96.27          69.17
0140T    Exhaled breath condensate ph                     A
0141T    Perq islet transplant                            E
0142T    Open islet transplant                            E
0143T    Laparoscopic islet transplnt                     E
0144T    CT heart wo dye; qual calc                       S      0398            4.1265      253.65             100.06             50.73
0145T    CT heart w/wo dye funct                          S      0376            4.9832      306.31             119.77             61.26
0146T    CCTA w/wo dye                                    S      0376            4.9832      306.31             119.77             61.26
0147T    CCTA w/wo, quan calcium                          S      0376            4.9832      306.31             119.77             61.26
0148T    CCTA w/wo, strxr                                 S      0377            6.5012      399.62             158.84             79.92
0149T    CCTA w/wo, strxr quan calc                       S      0377            6.5012      399.62             158.84             79.92
0150T    CCTA w/wo, disease strxr                         S      0398            4.1265      253.65             100.06             50.73
0151T    CT heart funct add-on                            S      0282            1.5379       94.53              37.81             18.91
0152T    Computer chest add-on                            N
0153T    Tcath sensor aneurysm sac                        C
0154T    Study sensor aneurysm sac                        X      0097            1.0225      $62.85              23.79        $12.57
0155T    Lap impl gast curve electrd              NF      T      0130           32.1241   $1,974.60             659.53       $394.92
0156T    Lap remv gast curve electrd              NF      T      0130           32.1241       1974.6            659.53         394.92
0157T    Open impl gast curve electrd             NF      C
0158T    Open remv gast curve electrd             NF      C
0159T    Cad breast mri                           NF      N
0160T    Tcranial magn stim tx plan               CH      S      0216            2.7199      167.19                                33.44
0161T    Tcranial magn stim tx deliv              CH      S      0216            2.7199      167.19                                33.44
0162T    Anal program gast neurostim              NI      S      0692            1.9323      118.77              30.16             23.75
0163T    Lumb artif diskectomy addl               NI      C
0164T    Remove lumb artif disc addl              NI      C
0165T    Revise lumb artif disc addl              NI      C
0166T    Tcath vsd close w/o bypass               NI      C
0167T    Tcath vsd close w bypass                 NI      C
0168T    Rhinophototx light app bilat             NI      T      0251            2.4520      150.72                                30.14
0169T    Place stereo cath brain                  NI      C
0170T    Anorectal fistula plug rpr               NI      T      0150     29.6189           1820.61             437.12         364.12
0171T    Lumbar spine proces distract             NI      T      0050     25.1296
                                                                   Milliman               $1,544.67                          $308.93
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                     61.468            2007 CF
                                                                                                    National            Minimum
HCPCS/                                                                         Relative            Unadjusted           Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment            Copayment
0172T    Lumbar spine proces addl                 NI      T      0050           25.1296   1544.67                           308.93
0173T    Iop monit io pressure                    NI      N
0174T    Cad cxr with interp                      NI      N
0175T    Cad cxr remote                           NI      N
0176T    Aqu canal dilat w/o retent               NI      T      0673           37.8967    2329.43            649.56         465.89
0177T    Aqu canal dilat w retent                 NI      T      0673           37.8967    2329.43            649.56         465.89
0500F    Initial prenatal care visit                      M
0501F    Prenatal flow sheet                              M
0502F    Subsequent prenatal care                         M
0503F    Postpartum care visit                            M
0505F    Hemodialysis plan doc'd                  NI      M
0507F    Periton dialysis plan doc'd              NI      M
1000F    Tobacco use assessed                             M
1001F    Tobacco use, non-smoking                 CH      D
1002F    Assess anginal symptom/level                     M
1003F    Level of activity assess                         M
1004F    Clin symp vol ovrld assess                       M
1005F    Asthma symptoms evaluate                         M
1006F    Osteoarthritis assess                            M
1007F    Anti-inflm/anlgsc otc assess                     M
1008F    Gi/renal risk assess                             M
1015F    Copd symptoms assess                     NI      M
1018F    Assess dyspnea not present               NI      M
1019F    Assess dyspnea present                   NI      M
1022F    Pneumo imm status assess                 NI      M
1026F    Co-morbid condition assess               NI      M
1030F    Influenza imm status assess              NI      M
1034F    Current tobacco smoker                   NI      M
1035F    Smokeless tobacco user                   NI      M
1036F    Tobacco non-user                         NI      M
1038F    Persistent asthma                        NI      M
1039F    Intermittent asthma                      NI      M
1040F    Dsm-ivÖ info mdd doc'd                   NI      M
2000F    Blood pressure measure                           M
2001F    Weight record                                    M
2002F    Clin sign vol ovrld assess                       M
2003F    Auscultation heart perform               CH      D
2004F    Initial exam involved joints                     M
2010F    Vital signs recorded                     NI      M
2014F    Mental status assess                     NI      M
2018F    Hydration status assess                  NI      M
2022F    Dil retina exam interp rev               NI      M
2024F    7 field photo interp doc rev             NI      M
2026F    Eye image valid to dx rev                NI      M
2028F    Foot exam performed                      NI      M
2030F    H2O stat docÆd, normal                   NI      M
2031F    H2O stat docÆd, dehydrated               NI      M
3000F    Blood press </= 140/90 mmhg              CH      D
3002F    Blood pressure > 140/90 mmhg             CH      D
3006F    Cxr doc rev                              NI      M
3011F    Lipid panel doc rev                      NI      M
3014F    Screen mammo doc rev                     NI      M
3017F    Colorectal ca screen doc rev             NI      M        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
3020F    Lvf assess                               NI      M
3021F    Lvef mod/sever deprs syst                NI      M
3022F    Lvef ?40% systolic                       NI      M
3023F    Spirom doc rev                           NI      M
3025F    Spirom fev/fvc<70% w copd                NI      M
3027F    Spirom fev/fvc?70%/ w/o copd             NI      M
3028F    O2 saturation doc rev                    NI      M
3035F    O2 saturation ?88% /pa0 ?55              NI      M
3037F    O2 saturation> 88% /pa0>55               NI      M
3040F    Fev<40% predicted value                  NI      M
3042F    Fev? 40% predicted value                 NI      M
3046F    Hemoglobin a1c level > 9.0%              NI      M
3047F    Hemoglobin A1c level ? 9.0%              NI      M
3048F    LDL-C <100 mg/dL                         NI      M
3049F    LDL-C 100-129 mg/dL                      NI      M
3050F    LDL-C ? 130 mg/dL                        NI      M
3060F    Pos microalbuminuria rev                 NI      M
3061F    Neg microalbuminuria rev                 NI      M
3062F    Pos macroalbuminuria rev                 NI      M
3066F    Nephropathy doc tx                       NI      M
3072F    Low risk for retinopathy                 NI      M
3076F    Syst bp < 140 mm hg                      NI      M
3077F    Syst bp ? 140 mm hg                      NI      M
3078F    Diast bp < 80 mm hg                      NI      M
3079F    Diast bp 80-89 mm hg                     NI      M
3080F    Diast bp ? 90 mm hg                      NI      M
3082F    Kt/v <1.2                                NI      M
3083F    Kt/v >= 1.2 and <1.7                     NI      M
3084F    Kt/v ? 1.7                               NI      M
3085F    Suicide risk assessed                    NI      M
3088F    Mdd, mild                                NI      M
3089F    Mdd, moderate                            NI      M
3090F    Mdd, severe; w/o psych                   NI      M
3091F    Mdd, severe; w/ psych                    NI      M
3092F    Mdd, in remission                        NI      M
3093F    Doc new diag 1st/addl. mdd               NI      M
4000F    Tobacco use txmnt counseling                     M
4001F    Tobacco use txmnt, pharmacol                     M
4002F    Statin therapy, rx                               M
4003F    Pt ed write/oral, pts w/ hf                      M
4006F    Beta-blocker therapy rx                          M
4009F    Ace inhibitor therapy rx                         M
4011F    Oral antiplatelet therapy rx                     M
4012F    Warfarin therapy rx                              M
4014F    Written discharge instr prvd                     M
4015F    Persist asthma medicine ctrl                     M
4016F    Anti-inflm/anlgsc agent rx                       M
4017F    Gi prophylaxis for nsaid rx                      M
4018F    Therapy exercise joint rx                        M
4025F    Inhaled broncholidator rx                NI      M
4030F    Oxygen therapy rx                        NI      M
4033F    Pulmonary rehab rec                      NI      M
4035F    Influenza imm rec                        NI      M        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
4037F    Influenza imm order/admin                NI      M
4040F    pneumoc imm order/admin                  NI      M
4045F    Empiric antibiotic rx                    NI      M
4050F    Ht care plan doc                         NI      M
4051F    Referred for an av fistula               NI      M
4052F    Hemodialysis via av fistula              NI      M
4053F    Hemodialysis via av graft                NI      M
4054F    Hemodialysis via catheter                NI      M
4055F    Pt. rcvng periton dialysis               NI      M
4056F    Approp. oral rehyd. recommÆd             NI      M
4058F    Ped gastro ed given, caregvr             NI      M
4060F    Psych svcs provided                      NI      M
4062F    Pt referral psych docÆd                  NI      M
4064F    Antidepressant rx                        NI      M
4065F    Antipsychotic rx                         NI      M
4066F    Ect provided                             NI      M
4067F    Pt referral for ect docÆd                NI      M
6005F    Care level rationale doc                 NI      M
A0021    Outside state ambulance serv                     E
A0080    Noninterest escort in non er                     E
A0090    Interest escort in non er                        E
A0100    Nonemergency transport taxi                      E
A0110    Nonemergency transport bus                       E
A0120    Noner transport mini-bus                         E
A0130    Noner transport wheelch van                      E
A0140    Nonemergency transport air                       E
A0160    Noner transport case worker                      E
A0170    Transport parking fees/tolls                     E
A0180    Noner transport lodgng recip                     E
A0190    Noner transport meals recip                      E
A0200    Noner transport lodgng escrt                     E
A0210    Noner transport meals escort                     E
A0225    Neonatal emergency transport                     A
A0380    Basic life support mileage                       A
A0382    Basic support routine suppls                     A
A0384    Bls defibrillation supplies                      A
A0390    Advanced life support mileag                     A
A0392    Als defibrillation supplies                      A
A0394    Als IV drug therapy supplies                     A
A0396    Als esophageal intub suppls                      A
A0398    Als routine disposble suppls                     A
A0420    Ambulance waiting 1/2 hr                         A
A0422    Ambulance 02 life sustaining                     A
A0424    Extra ambulance attendant                        A
A0425    Ground mileage                                   A
A0426    Als 1                                            A
A0427    ALS1-emergency                                   A
A0428    bls                                              A
A0429    BLS-emergency                                    A
A0430    Fixed wing air transport                         A
A0431    Rotary wing air transport                        A
A0432    PI volunteer ambulance co                        A
A0433    als 2                                            A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A0434    Specialty care transport                         A
A0435    Fixed wing air mileage                           A
A0436    Rotary wing air mileage                          A
A0800    Amb trans 7pm-7am                        CH      D
A0888    Noncovered ambulance mileage                     E
A0998    Ambulance response/treatment                     E
A0999    Unlisted ambulance service                       A
A4206    1 CC sterile syringe&needle                      E
A4207    2 CC sterile syringe&needle                      E
A4208    3 CC sterile syringe&needle                      E
A4209    5+ CC sterile syringe&needle                     E
A4210    Nonneedle injection device                       E
A4211    Supp for self-adm injections             CH      E
A4212    Non coring needle or stylet                      B
A4213    20+ CC syringe only                              E
A4215    Sterile needle                                   E
A4216    Sterile water/saline, 10 ml                      A
A4217    Sterile water/saline, 500 ml                     A
A4218    Sterile saline or water                          N
A4220    Infusion pump refill kit                         N
A4221    Maint drug infus cath per wk                     Y
A4222    Infusion supplies with pump                      Y
A4223    Infusion supplies w/o pump                       E
A4230    Infus insulin pump non needl                     Y
A4231    Infusion insulin pump needle                     Y
A4232    Syringe w/needle insulin 3cc                     E
A4233    Alkalin batt for glucose mon                     Y
A4234    J-cell batt for glucose mon                      Y
A4235    Lithium batt for glucose mon                     Y
A4236    Silvr oxide batt glucose mon                     Y
A4244    Alcohol or peroxide per pint                     E
A4245    Alcohol wipes per box                            E
A4246    Betadine/phisohex solution                       E
A4247    Betadine/iodine swabs/wipes                      E
A4248    Chlorhexidine antisept                           N
A4250    Urine reagent strips/tablets                     E
A4253    Blood glucose/reagent strips                     Y
A4255    Glucose monitor platforms                        Y
A4256    Calibrator solution/chips                        Y
A4257    Replace Lensshield Cartridge                     Y
A4258    Lancet device each                               Y
A4259    Lancets per box                                  Y
A4261    Cervical cap contraceptive                       E
A4262    Temporary tear duct plug                         N
A4263    Permanent tear duct plug                         N
A4265    Paraffin                                         Y
A4266    Diaphragm                                        E
A4267    Male condom                                      E
A4268    Female condom                                    E
A4269    Spermicide                                       E
A4270    Disposable endoscope sheath                      N
A4280    Brst prsths adhsv attchmnt                       A
A4281    Replacement breastpump tube                      E        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A4282    Replacement breastpump adpt                      E
A4283    Replacement breastpump cap                       E
A4284    Replcmnt breast pump shield                      E
A4285    Replcmnt breast pump bottle                      E
A4286    Replcmnt breastpump lok ring                     E
A4290    Sacral nerve stim test lead                      B
A4300    Cath impl vasc access portal                     N
A4301    Implantable access syst perc                     N
A4305    Drug delivery system >=50 ML             CH      N
A4306    Drug delivery system <=50 ml             CH      N
A4310    Insert tray w/o bag/cath                         A
A4311    Catheter w/o bag 2-way latex                     A
A4312    Cath w/o bag 2-way silicone                      A
A4313    Catheter w/bag 3-way                             A
A4314    Cath w/drainage 2-way latex                      A
A4315    Cath w/drainage 2-way silcne                     A
A4316    Cath w/drainage 3-way                            A
A4320    Irrigation tray                                  A
A4321    Cath therapeutic irrig agent                     A
A4322    Irrigation syringe                               A
A4326    Male external catheter                           A
A4327    Fem urinary collect dev cup                      A
A4328    Fem urinary collect pouch                        A
A4330    Stool collection pouch                           A
A4331    Extension drainage tubing                        A
A4332    Lube sterile packet                              A
A4333    Urinary cath anchor device                       A
A4334    Urinary cath leg strap                           A
A4335    Incontinence supply                              A
A4338    Indwelling catheter latex                        A
A4340    Indwelling catheter special                      A
A4344    Cath indw foley 2 way silicn                     A
A4346    Cath indw foley 3 way                            A
A4348    Male ext cath extended wear              CH      D
A4349    Disposable male external cat                     A
A4351    Straight tip urine catheter                      A
A4352    Coude tip urinary catheter                       A
A4353    Intermittent urinary cath                        A
A4354    Cath insertion tray w/bag                        A
A4355    Bladder irrigation tubing                        A
A4356    Ext ureth clmp or compr dvc                      A
A4357    Bedside drainage bag                             A
A4358    Urinary leg or abdomen bag                       A
A4359    Urinary suspensory w/o leg b             CH      D
A4361    Ostomy face plate                                A
A4362    Solid skin barrier                               A
A4363    Ostomy clamp, replacement                        A
A4364    Adhesive, liquid or equal                        A
A4365    Adhesive remover wipes                           A
A4366    Ostomy vent                                      A
A4367    Ostomy belt                                      A
A4368    Ostomy filter                                    A
A4369    Skin barrier liquid per oz                       A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 155 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A4371    Skin barrier powder per oz                       A
A4372    Skin barrier solid 4x4 equiv                     A
A4373    Skin barrier with flange                         A
A4375    Drainable plastic pch w fcpl                     A
A4376    Drainable rubber pch w fcplt                     A
A4377    Drainable plstic pch w/o fp                      A
A4378    Drainable rubber pch w/o fp                      A
A4379    Urinary plastic pouch w fcpl                     A
A4380    Urinary rubber pouch w fcplt                     A
A4381    Urinary plastic pouch w/o fp                     A
A4382    Urinary hvy plstc pch w/o fp                     A
A4383    Urinary rubber pouch w/o fp                      A
A4384    Ostomy faceplt/silicone ring                     A
A4385    Ost skn barrier sld ext wear                     A
A4387    Ost clsd pouch w att st barr                     A
A4388    Drainable pch w ex wear barr                     A
A4389    Drainable pch w st wear barr                     A
A4390    Drainable pch ex wear convex                     A
A4391    Urinary pouch w ex wear barr                     A
A4392    Urinary pouch w st wear barr                     A
A4393    Urine pch w ex wear bar conv                     A
A4394    Ostomy pouch liq deodorant                       A
A4395    Ostomy pouch solid deodorant                     A
A4396    Peristomal hernia supprt blt                     A
A4397    Irrigation supply sleeve                         A
A4398    Ostomy irrigation bag                            A
A4399    Ostomy irrig cone/cath w brs                     A
A4400    Ostomy irrigation set                            A
A4402    Lubricant per ounce                              A
A4404    Ostomy ring each                                 A
A4405    Nonpectin based ostomy paste                     A
A4406    Pectin based ostomy paste                        A
A4407    Ext wear ost skn barr <=4sqö                     A
A4408    Ext wear ost skn barr >4sqö                      A
A4409    Ost skn barr convex <=4 sq i                     A
A4410    Ost skn barr extnd >4 sq                         A
A4411    Ost skn barr extnd =4sq                          A
A4412    Ost pouch drain high output                      A
A4413    2 pc drainable ost pouch                         A
A4414    Ost sknbar w/o conv<=4 sq in                     A
A4415    Ost skn barr w/o conv >4 sqi                     A
A4416    Ost pch clsd w barrier/filtr                     A
A4417    Ost pch w bar/bltinconv/fltr                     A
A4418    Ost pch clsd w/o bar w filtr                     A
A4419    Ost pch for bar w flange/flt                     A
A4420    Ost pch clsd for bar w lk fl                     A
A4421    Ostomy supply misc                               E
A4422    Ost pouch absorbent material                     A
A4423    Ost pch for bar w lk fl/fltr                     A
A4424    Ost pch drain w bar & filter                     A
A4425    Ost pch drain for barrier fl                     A
A4426    Ost pch drain 2 piece system                     A
A4427    Ost pch drain/barr lk flng/f                     A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 156 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A4428    Urine ost pouch w faucet/tap                     A
A4429    Urine ost pouch w bltinconv                      A
A4430    Ost urine pch w b/bltin conv                     A
A4431    Ost pch urine w barrier/tapv                     A
A4432    Os pch urine w bar/fange/tap                     A
A4433    Urine ost pch bar w lock fln                     A
A4434    Ost pch urine w lock flng/ft                     A
A4450    Non-waterproof tape                              A
A4452    Waterproof tape                                  A
A4455    Adhesive remover per ounce                       A
A4458    Reusable enema bag                               E
A4461    Surgicl dress hold non-reuse             NI      A
A4462    Abdmnl drssng holder/binder              CH      D
A4463    Surgical dress holder reuse              NI      A
A4465    Non-elastic extremity binder                     A
A4470    Gravlee jet washer                               A
A4480    Vabra aspirator                                  A
A4481    Tracheostoma filter                              A
A4483    Moisture exchanger                               A
A4490    Above knee surgical stocking                     E
A4495    Thigh length surg stocking                       E
A4500    Below knee surgical stocking                     E
A4510    Full length surg stocking                        E
A4520    Incontinence garment anytype                     E
A4550    Surgical trays                                   B
A4554    Disposable underpads                             E
A4556    Electrodes, pair                                 Y
A4557    Lead wires, pair                                 Y
A4558    Conductive gel or paste                          Y
A4559    Coupling gel or paste                    NI      Y
A4561    Pessary rubber, any type                         N
A4562    Pessary, non rubber,any type                     N
A4565    Slings                                           A
A4570    Splint                                           E
A4575    Hyperbaric o2 chamber disps                      E
A4580    Cast supplies (plaster)                          E
A4590    Special casting material                         E
A4595    TENS suppl 2 lead per month                      Y
A4600    Sleeve, inter limb comp dev              NI      Y
A4601    Lith ion batt, non-pros use              NI      Y
A4604    Tubing with heating element                      Y
A4605    Trach suction cath close sys                     Y
A4606    Oxygen probe used w oximeter                     A
A4608    Transtracheal oxygen cath                        Y
A4611    Heavy duty battery                               Y
A4612    Battery cables                                   Y
A4613    Battery charger                                  Y
A4614    Hand-held PEFR meter                     CH      N
A4615    Cannula nasal                                    Y
A4616    Tubing (oxygen) per foot                         Y
A4617    Mouth piece                                      Y
A4618    Breathing circuits                               Y
A4619    Face tent                                        Y        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A4620    Variable concentration mask                      Y
A4623    Tracheostomy inner cannula                       A
A4624    Tracheal suction tube                            Y
A4625    Trach care kit for new trach                     A
A4626    Tracheostomy cleaning brush                      A
A4627    Spacer bag/reservoir                             E
A4628    Oropharyngeal suction cath                       Y
A4629    Tracheostomy care kit                            A
A4630    Repl bat t.e.n.s. own by pt                      Y
A4632    Infus pump rplcemnt battery              CH      D
A4633    Uvl replacement bulb                             Y
A4634    Replacement bulb th lightbox                     A
A4635    Underarm crutch pad                              Y
A4636    Handgrip for cane etc                            Y
A4637    Repl tip cane/crutch/walker                      Y
A4638    Repl batt pulse gen sys                          Y
A4639    Infrared ht sys replcmnt pad                     Y
A4640    Alternating pressure pad                         Y
A4641    Radiopharm dx agent noc                          N
A4642    In111 satumomab                                  H      0704
A4649    Surgical supplies                                A
A4651    Calibrated microcap tube                         A
A4652    Microcapillary tube sealant                      A
A4653    PD catheter anchor belt                          A
A4657    Syringe w/wo needle                              A
A4660    Sphyg/bp app w cuff and stet                     A
A4663    Dialysis blood pressure cuff                     A
A4670    Automatic bp monitor, dial                       E
A4671    Disposable cycler set                            B
A4672    Drainage ext line, dialysis                      B
A4673    Ext line w easy lock connect                     B
A4674    Chem/antisept solution, 8oz                      B
A4680    Activated carbon filter, ea                      A
A4690    Dialyzer, each                                   A
A4706    Bicarbonate conc sol per gal                     A
A4707    Bicarbonate conc pow per pac                     A
A4708    Acetate conc sol per gallon                      A
A4709    Acid conc sol per gallon                         A
A4714    Treated water per gallon                         A
A4719    "Y set" tubing                                   A
A4720    Dialysat sol fld vol > 249cc                     A
A4721    Dialysat sol fld vol > 999cc                     A
A4722    Dialys sol fld vol > 1999cc                      A
A4723    Dialys sol fld vol > 2999cc                      A
A4724    Dialys sol fld vol > 3999cc                      A
A4725    Dialys sol fld vol > 4999cc                      A
A4726    Dialys sol fld vol > 5999cc                      A
A4728    Dialysate solution, non-dex                      B
A4730    Fistula cannulation set, ea                      A
A4736    Topical anesthetic, per gram                     A
A4737    Inj anesthetic per 10 ml                         A
A4740    Shunt accessory                                  A
A4750    Art or venous blood tubing                       A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 158 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A4755    Comb art/venous blood tubing                     A
A4760    Dialysate sol test kit, each                     A
A4765    Dialysate conc pow per pack                      A
A4766    Dialysate conc sol add 10 ml                     A
A4770    Blood collection tube/vacuum                     A
A4771    Serum clotting time tube                         A
A4772    Blood glucose test strips                        A
A4773    Occult blood test strips                         A
A4774    Ammonia test strips                              A
A4802    Protamine sulfate per 50 mg                      A
A4860    Disposable catheter tips                         A
A4870    Plumb/elec wk hm hemo equip                      A
A4890    Repair/maint cont hemo equip                     A
A4911    Drain bag/bottle                                 A
A4913    Misc dialysis supplies noc                       A
A4918    Venous pressure clamp                            A
A4927    Non-sterile gloves                               A
A4928    Surgical mask                                    A
A4929    Tourniquet for dialysis, ea                      A
A4930    Sterile, gloves per pair                         A
A4931    Reusable oral thermometer                        A
A4932    Reusable rectal thermometer                      E
A5051    Pouch clsd w barr attached                       A
A5052    Clsd ostomy pouch w/o barr                       A
A5053    Clsd ostomy pouch faceplate                      A
A5054    Clsd ostomy pouch w/flange                       A
A5055    Stoma cap                                        A
A5061    Pouch drainable w barrier at                     A
A5062    Drnble ostomy pouch w/o barr                     A
A5063    Drain ostomy pouch w/flange                      A
A5071    Urinary pouch w/barrier                          A
A5072    Urinary pouch w/o barrier                        A
A5073    Urinary pouch on barr w/flng                     A
A5081    Continent stoma plug                             A
A5082    Continent stoma catheter                         A
A5093    Ostomy accessory convex inse                     A
A5102    Bedside drain btl w/wo tube                      A
A5105    Urinary suspensory                               A
A5112    Urinary leg bag                                  A
A5113    Latex leg strap                                  A
A5114    Foam/fabric leg strap                            A
A5120    Skin barrier, wipe or swab                       A
A5121    Solid skin barrier 6x6                           A
A5122    Solid skin barrier 8x8                           A
A5126    Disk/foam pad +or- adhesive                      A
A5131    Appliance cleaner                                A
A5200    Percutaneous catheter anchor                     A
A5500    Diab shoe for density insert                     Y
A5501    Diabetic custom molded shoe                      Y
A5503    Diabetic shoe w/roller/rockr                     Y
A5504    Diabetic shoe with wedge                         Y
A5505    Diab shoe w/metatarsal bar                       Y
A5506    Diabetic shoe w/off set heel                     Y        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 159 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A5507    Modification diabetic shoe                       Y
A5508    Diabetic deluxe shoe                             Y
A5510    Compression form shoe insert                     E
A5512    Multi den insert direct form             CH      Y
A5513    Multi den insert custom mold             CH      Y
A6000    Wound warming wound cover                        E
A6010    Collagen based wound filler                      A
A6011    Collagen gel/paste wound fil                     A
A6021    Collagen dressing <=16 sq in                     A
A6022    Collagen drsg>6<=48 sq in                        A
A6023    Collagen dressing >48 sq in                      A
A6024    Collagen dsg wound filler                        A
A6025    Silicone gel sheet, each                         E
A6154    Wound pouch each                                 A
A6196    Alginate dressing <=16 sq in                     A
A6197    Alginate drsg >16 <=48 sq in                     A
A6198    alginate dressing > 48 sq in                     A
A6199    Alginate drsg wound filler                       A
A6200    Compos drsg <=16 no border                       A
A6201    Compos drsg >16<=48 no bdr                       A
A6202    Compos drsg >48 no border                        A
A6203    Composite drsg <= 16 sq in                       A
A6204    Composite drsg >16<=48 sq in                     A
A6205    Composite drsg > 48 sq in                        A
A6206    Contact layer <= 16 sq in                        A
A6207    Contact layer >16<= 48 sq in                     A
A6208    Contact layer > 48 sq in                         A
A6209    Foam drsg <=16 sq in w/o bdr                     A
A6210    Foam drg >16<=48 sq in w/o b                     A
A6211    Foam drg > 48 sq in w/o brdr                     A
A6212    Foam drg <=16 sq in w/border                     A
A6213    Foam drg >16<=48 sq in w/bdr                     A
A6214    Foam drg > 48 sq in w/border                     A
A6215    Foam dressing wound filler                       A
A6216    Non-sterile gauze<=16 sq in                      A
A6217    Non-sterile gauze>16<=48 sq                      A
A6218    Non-sterile gauze > 48 sq in                     A
A6219    Gauze <= 16 sq in w/border                       A
A6220    Gauze >16 <=48 sq in w/bordr                     A
A6221    Gauze > 48 sq in w/border                        A
A6222    Gauze <=16 in no w/sal w/o b                     A
A6223    Gauze >16<=48 no w/sal w/o b                     A
A6224    Gauze > 48 in no w/sal w/o b                     A
A6228    Gauze <= 16 sq in water/sal                      A
A6229    Gauze >16<=48 sq in watr/sal                     A
A6230    Gauze > 48 sq in water/salne                     A
A6231    Hydrogel dsg<=16 sq in                           A
A6232    Hydrogel dsg>16<=48 sq in                        A
A6233    Hydrogel dressing >48 sq in                      A
A6234    Hydrocolld drg <=16 w/o bdr                      A
A6235    Hydrocolld drg >16<=48 w/o b                     A
A6236    Hydrocolld drg > 48 in w/o b                     A
A6237    Hydrocolld drg <=16 in w/bdr                     A        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 160 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A6238    Hydrocolld drg >16<=48 w/bdr                     A
A6239    Hydrocolld drg > 48 in w/bdr                     A
A6240    Hydrocolld drg filler paste                      A
A6241    Hydrocolloid drg filler dry                      A
A6242    Hydrogel drg <=16 in w/o bdr                     A
A6243    Hydrogel drg >16<=48 w/o bdr                     A
A6244    Hydrogel drg >48 in w/o bdr                      A
A6245    Hydrogel drg <= 16 in w/bdr                      A
A6246    Hydrogel drg >16<=48 in w/b                      A
A6247    Hydrogel drg > 48 sq in w/b                      A
A6248    Hydrogel drsg gel filler                         A
A6250    Skin seal protect moisturizr                     A
A6251    Absorpt drg <=16 sq in w/o b                     A
A6252    Absorpt drg >16 <=48 w/o bdr                     A
A6253    Absorpt drg > 48 sq in w/o b                     A
A6254    Absorpt drg <=16 sq in w/bdr                     A
A6255    Absorpt drg >16<=48 in w/bdr                     A
A6256    Absorpt drg > 48 sq in w/bdr                     A
A6257    Transparent film <= 16 sq in                     A
A6258    Transparent film >16<=48 in                      A
A6259    Transparent film > 48 sq in                      A
A6260    Wound cleanser any type/size                     A
A6261    Wound filler gel/paste /oz                       A
A6262    Wound filler dry form / gram                     A
A6266    Impreg gauze no h20/sal/yard                     A
A6402    Sterile gauze <= 16 sq in                        A
A6403    Sterile gauze>16 <= 48 sq in                     A
A6404    Sterile gauze > 48 sq in                         A
A6407    Packing strips, non-impreg                       A
A6410    Sterile eye pad                                  A
A6411    Non-sterile eye pad                              A
A6412    Occlusive eye patch                              E
A6441    Pad band w>=3ö <5ö/yd                            A
A6442    Conform band n/s w<3ö/yd                         A
A6443    Conform band n/s w>=3ö<5ö/yd                     A
A6444    Conform band n/s w>=5ö/yd                        A
A6445    Conform band s w <3ö/yd                          A
A6446    Conform band s w>=3ö <5ö/yd                      A
A6447    Conform band s w >=5ö/yd                         A
A6448    Lt compres band <3ö/yd                           A
A6449    Lt compres band >=3ö <5ö/yd                      A
A6450    Lt compres band >=5ö/yd                          A
A6451    Mod compres band w>=3ö<5ö/yd                     A
A6452    High compres band w>=3ö<5öyd                     A
A6453    Self-adher band w <3ö/yd                         A
A6454    Self-adher band w>=3ö <5ö/yd                     A
A6455    Self-adher band >=5ö/yd                          A
A6456    Zinc paste band w >=3ö<5ö/yd                     A
A6457    Tubular dressing                                 A
A6501    Compres burngarment bodysuit                     A
A6502    Compres burngarment chinstrp                     A
A6503    Compres burngarment facehood                     A
A6504    Cmprsburngarment glove-wrist                     A        Milliman
     pai 7/26/2012 2:18 PM
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A6505    Cmprsburngarment glove-elbow                     A
A6506    Cmprsburngrmnt glove-axilla                      A
A6507    Cmprs burngarment foot-knee                      A
A6508    Cmprs burngarment foot-thigh                     A
A6509    Compres burn garment jacket                      A
A6510    Compres burn garment leotard                     A
A6511    Compres burn garment panty                       A
A6512    Compres burn garment, noc                        A
A6513    Compress burn mask face/neck                     B
A6530    Compression stocking BK18-30                     E
A6531    Compression stocking BK30-40                     A
A6532    Compression stocking BK40-50                     A
A6533    Gc stocking thighlngth 18-30                     E
A6534    Gc stocking thighlngth 30-40                     E
A6535    Gc stocking thighlngth 40-50                     E
A6536    Gc stocking full lngth 18-30                     E
A6537    Gc stocking full lngth 30-40                     E
A6538    Gc stocking full lngth 40-50                     E
A6539    Gc stocking waistlngth 18-30                     E
A6540    Gc stocking waistlngth 30-40                     E
A6541    Gc stocking waistlngth 40-50                     E
A6542    Gc stocking custom made                          E
A6543    Gc stocking lymphedema                           E
A6544    Gc stocking garter belt                          E
A6549    G compression stocking                           E
A6550    Neg pres wound ther drsg set                     Y
A7000    Disposable canister for pump                     Y
A7001    Nondisposable pump canister                      Y
A7002    Tubing used w suction pump                       Y
A7003    Nebulizer administration set                     Y
A7004    Disposable nebulizer sml vol                     Y
A7005    Nondisposable nebulizer set                      Y
A7006    Filtered nebulizer admin set                     Y
A7007    Lg vol nebulizer disposable                      Y
A7008    Disposable nebulizer prefill                     Y
A7009    Nebulizer reservoir bottle                       Y
A7010    Disposable corrugated tubing                     Y
A7011    Nondispos corrugated tubing                      Y
A7012    Nebulizer water collec devic                     Y
A7013    Disposable compressor filter                     Y
A7014    Compressor nondispos filter                      Y
A7015    Aerosol mask used w nebulize                     Y
A7016    Nebulizer dome & mouthpiece                      Y
A7017    Nebulizer not used w oxygen                      Y
A7018    Water distilled w/nebulizer                      Y
A7025    Replace chest compress vest                      Y
A7026    Replace chst cmprss sys hose                     Y
A7030    CPAP full face mask                              Y
A7031    Replacement facemask interfa                     Y
A7032    Replacement nasal cushion                        Y
A7033    Replacement nasal pillows                        Y
A7034    Nasal application device                         Y
A7035    Pos airway press headgear                        Y        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A7036    Pos airway press chinstrap                       Y
A7037    Pos airway pressure tubing                       Y
A7038    Pos airway pressure filter                       Y
A7039    Filter, non disposable w pap                     Y
A7040    One way chest drain valve                        A
A7041    Water seal drain container                       A
A7042    Implanted pleural catheter                       A
A7043    Vacuum drainagebottle/tubing                     A
A7044    PAP oral interface                               Y
A7045    Repl exhalation port for PAP                     Y
A7046    Repl water chamber, PAP dev                      Y
A7501    Tracheostoma valve w diaphra                     A
A7502    Replacement diaphragm/fplate                     A
A7503    HMES filter holder or cap                        A
A7504    Tracheostoma HMES filter                         A
A7505    HMES or trach valve housing                      A
A7506    HMES/trachvalve adhesivedisk                     A
A7507    Integrated filter & holder                       A
A7508    Housing & Integrated Adhesiv                     A
A7509    Heat & moisture exchange sys                     A
A7520    Trach/laryn tube non-cuffed                      A
A7521    Trach/laryn tube cuffed                          A
A7522    Trach/laryn tube stainless                       A
A7523    Tracheostomy shower protect                      A
A7524    Tracheostoma stent/stud/bttn                     A
A7525    Tracheostomy mask                                A
A7526    Tracheostomy tube collar                         A
A7527    Trach/laryn tube plug/stop                       A
A8000    Soft protect helmet prefab               NI      Y
A8001    Hard protect helmet prefab               NI      Y
A8002    Soft protect helmet custom               NI      Y
A8003    Hard protect helmet custom               NI      Y
A8004    Repl soft interface, helmet              NI      Y
A9150    Misc/exper non-prescript dru                     B
A9152    Single vitamin nos                               E
A9153    Multi-vitamin nos                                E
A9180    Lice treatment, topical                          E
A9270    Non-covered item or service                      E
A9275    Disp home glucose monitor                        E
A9279    Monitoring feature/deviceNOC             NI      E
A9280    Alert device, noc                                E
A9281    Reaching/grabbing device                         E
A9282    Wig any type                                     E
A9300    Exercise equipment                               E
A9500    Tc99m sestamibi                                  H      1600
A9502    Tc99m tetrofosmin                                H      0705
A9503    Tc99m medronate                                  N
A9504    Tc99m apcitide                           CH      N
A9505    TL201 thallium                                   H      1603
A9507    In111 capromab                                   H      1604
A9508    I131 iodobenguate, dx                            H      1045
A9510    Tc99m disofenin                          CH      N
A9512    Tc99m pertechnetate                              N        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468      2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
A9516    I123 iodide cap, dx                      CH      H      9148
A9517    I131 iodide cap, rx                      CH      H      1064
A9521    Tc99m exametazime                                H      1096
A9524    I131 serum albumin, dx                           H      9100
A9526    Nitrogen N-13 ammonia                            H      0737
A9527    Iodine I-125 sodium iodide               NI      K      2632            0.3321         20.41                         4.08
A9528    Iodine I-131 iodide cap, dx                      H      1088
A9529    I131 iodide sol, dx                      CH      N
A9530    I131 iodide sol, rx                              H      1150
A9531    I131 max 100uCi                          CH      N
A9532    I125 serum albumin, dx                   CH      N
A9535    Injection, methylene blue                CH      N
A9536    Tc99m depreotide                         CH      H      0739
A9537    Tc99m mebrofenin                                 N
A9538    Tc99m pyrophosphate                              N
A9539    Tc99m pentetate                          CH      H      0722
A9540    Tc99m MAA                                        N
A9541    Tc99m sulfur colloid                             N
A9542    In111 ibritumomab, dx                            H      1642
A9543    Y90 ibritumomab, rx                              H      1643
A9544    I131 tositumomab, dx                             H      1644
A9545    I131 tositumomab, rx                             H      1645
A9546    Co57/58                                  CH      H      0723
A9547    In111 oxyquinoline                               H      1646
A9548    In111 pentetate                                  H      1647
A9549    Tc99m arcitumomab                        CH      D
A9550    Tc99m gluceptate                         CH      H      0740
A9551    Tc99m succimer                                   H      1650
A9552    F18 fdg                                          H      1651
A9553    Cr51 chromate                            CH      H      0741
A9554    I125 iothalamate, dx                     CH      N
A9555    Rb82 rubidium                                    H      1654
A9556    Ga67 gallium                                     H      1671
A9557    Tc99m bicisate                                   H      1672
A9558    Xe133 xenon 10mci                                N
A9559    Co57 cyano                               CH      H      0724
A9560    Tc99m labeled rbc                        CH      H      0742
A9561    Tc99m oxidronate                                 N
A9562    Tc99m mertiatide                         CH      H      0743
A9563    P32 Na phosphate                                 H      1675
A9564    P32 chromic phosphate                            H      1676
A9565    In111 pentetreotide                              H      1677
A9566    Tc99m fanolesomab                                H      1678
A9567    Technetium TC-99m aerosol                CH      H      0829
A9568    Technetium tc99m arcitumomab             NI      H      1648
A9600    Sr89 strontium                                   H      0701
A9605    Sm 153 lexidronm                                 H      0702
A9698    Non-rad contrast materialNOC                     N
A9699    Radiopharm rx agent noc                          N
A9700    Echocardiography Contrast                        B
A9900    Supply/accessory/service                 CH      Y
A9901    Delivery/set up/dispensing                       A
A9999    DME supply or accessory, nos                     Y        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468      2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
B4034    Enter feed supkit syr by day             CH      Y
B4035    Enteral feed supp pump per d             CH      Y
B4036    Enteral feed sup kit grav by             CH      Y
B4081    Enteral ng tubing w/ stylet              CH      Y
B4082    Enteral ng tubing w/o stylet             CH      Y
B4083    Enteral stomach tube levine              CH      Y
B4086    Gastrostomy/jejunostomy tube             CH      Y
B4100    Food thickener oral                              E
B4102    EF adult fluids and electro              CH      Y
B4103    EF ped fluid and electrolyte             CH      Y
B4104    Additive for enteral formula                     E
B4149    EF blenderized foods                     CH      Y
B4150    EF complet w/intact nutrient             CH      Y
B4152    EF calorie dense>/=1.5Kcal               CH      Y
B4153    EF hydrolyzed/amino acids                CH      Y
B4154    EF spec metabolic noninherit             CH      Y
B4155    EF incomplete/modular                    CH      Y
B4157    EF special metabolic inherit             CH      Y
B4158    EF ped complete intact nut               CH      Y
B4159    EF ped complete soy based                CH      Y
B4160    EF ped caloric dense>/=0.7kc             CH      Y
B4161    EF ped hydrolyzed/amino acid             CH      Y
B4162    EF ped specmetabolic inherit             CH      Y
B4164    Parenteral 50% dextrose solu             CH      Y
B4168    Parenteral sol amino acid 3.             CH      Y
B4172    Parenteral sol amino acid 5.             CH      Y
B4176    Parenteral sol amino acid 7-             CH      Y
B4178    Parenteral sol amino acid >              CH      Y
B4180    Parenteral sol carb > 50%                CH      Y
B4185    Parenteral sol 10 gm lipids                      B
B4189    Parenteral sol amino acid &              CH      Y
B4193    Parenteral sol 52-73 gm prot             CH      Y
B4197    Parenteral sol 74-100 gm pro             CH      Y
B4199    Parenteral sol > 100gm prote             CH      Y
B4216    Parenteral nutrition additiv             CH      Y
B4220    Parenteral supply kit premix             CH      Y
B4222    Parenteral supply kit homemi             CH      Y
B4224    Parenteral administration ki             CH      Y
B5000    Parenteral sol renal-amirosy             CH      Y
B5100    Parenteral sol hepatic-fream             CH      Y
B5200    Parenteral sol stres-brnch c             CH      Y
B9000    Enter infusion pump w/o alrm             CH      Y
B9002    Enteral infusion pump w/ ala             CH      Y
B9004    Parenteral infus pump portab             CH      Y
B9006    Parenteral infus pump statio             CH      Y
B9998    Enteral supp not otherwise c             CH      Y
B9999    Parenteral supp not othrws c             CH      Y
C1178    BUSULFAN IV, 6 Mg                        CH      D
C1300    HYPERBARIC Oxygen                                S      0659            1.5906         97.77                         19.55
C1713    Anchor/screw bn/bn,tis/bn                        N
C1714    Cath, trans atherectomy, dir                     N
C1715    Brachytherapy needle                             N
C1716    Brachytx source, Gold 198                CH      K        Milliman 0.5991
                                                                 1716                           36.83                          7.37
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468        2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
C1717    Brachytx source, HDR Ir-192              CH      K      1717            2.3195        142.58                      28.52
C1718    Brachytx source, Iodine 125              CH      K      1718            0.5910         36.33                       7.27
C1719    Brachytx sour,Non-HDR Ir-192             CH      K      1719            0.3765         23.14                       4.63
C1720    Brachytx sour, Palladium 103             CH      K      1720            0.7942         48.82                       9.76
C1721    AICD, dual chamber                               N
C1722    AICD, single chamber                             N
C1724    Cath, trans atherec,rotation                     N
C1725    Cath, translumin non-laser                       N
C1726    Cath, bal dil, non-vascular                      N
C1727    Cath, bal tis dis, non-vas                       N
C1728    Cath, brachytx seed adm                          N
C1729    Cath, drainage                                   N
C1730    Cath, EP, 19 or few elect                        N
C1731    Cath, EP, 20 or more elec                        N
C1732    Cath, EP, diag/abl, 3D/vect                      N
C1733    Cath, EP, othr than cool-tip                     N
C1750    Cath, hemodialysis,long-term                     N
C1751    Cath, inf, per/cent/midline                      N
C1752    Cath,hemodialysis,short-term                     N
C1753    Cath, intravas ultrasound                        N
C1754    Catheter, intradiscal                            N
C1755    Catheter, intraspinal                            N
C1756    Cath, pacing, transesoph                         N
C1757    Cath, thrombectomy/embolect                      N
C1758    Catheter, ureteral                               N
C1759    Cath, intra echocardiography                     N
C1760    Closure dev, vasc                                N
C1762    Conn tiss, human(inc fascia)                     N
C1763    Conn tiss, non-human                             N
C1764    Event recorder, cardiac                          N
C1765    Adhesion barrier                                 N
C1766    Intro/sheath,strble,non-peel                     N
C1767    Generator, neuro non-recharg                     N
C1768    Graft, vascular                                  N
C1769    Guide wire                                       N
C1770    Imaging coil, MR, insertable                     N
C1771    Rep dev, urinary, w/sling                        N
C1772    Infusion pump, programmable                      N
C1773    Ret dev, insertable                              N
C1776    Joint device (implantable)                       N
C1777    Lead, AICD, endo single coil                     N
C1778    Lead, neurostimulator                            N
C1779    Lead, pmkr, transvenous VDD                      N
C1780    Lens, intraocular (new tech)                     N
C1781    Mesh (implantable)                               N
C1782    Morcellator                                      N
C1783    Ocular imp, aqueous drain de                     N
C1784    Ocular dev, intraop, det ret                     N
C1785    Pmkr, dual, rate-resp                            N
C1786    Pmkr, single, rate-resp                          N
C1787    Patient progr, neurostim                         N
C1788    Port, indwelling, imp                            N
C1789    Prosthesis, breast, imp                          N        Milliman
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468      2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
C1813    Prosthesis, penile, inflatab                     N
C1814    Retinal tamp, silicone oil                       N
C1815    Pros, urinary sph, imp                           N
C1816    Receiver/transmitter, neuro                      N
C1817    Septal defect imp sys                            N
C1818    Integrated keratoprosthesis                      N
C1819    Tissue localization-excision                     N
C1820    Generator neuro rechg bat sy                     H      1820
C1821    Interspinous implant                     NI      H      1821
C1874    Stent, coated/cov w/del sys                      N
C1875    Stent, coated/cov w/o del sy                     N
C1876    Stent, non-coa/non-cov w/del                     N
C1877    Stent, non-coat/cov w/o del                      N
C1878    Matrl for vocal cord                             N
C1879    Tissue marker, implantable                       N
C1880    Vena cava filter                                 N
C1881    Dialysis access system                           N
C1882    AICD, other than sing/dual                       N
C1883    Adapt/ext, pacing/neuro lead                     N
C1884    Embolization Protect syst                        N
C1885    Cath, translumin angio laser                     N
C1887    Catheter, guiding                                N
C1888    Endovas non-cardiac abl cath                     N
C1891    Infusion pump,non-prog, perm                     N
C1892    Intro/sheath,fixed,peel-away                     N
C1893    Intro/sheath, fixed,non-peel                     N
C1894    Intro/sheath, non-laser                          N
C1895    Lead, AICD, endo dual coil                       N
C1896    Lead, AICD, non sing/dual                        N
C1897    Lead, neurostim test kit                         N
C1898    Lead, pmkr, other than trans                     N
C1899    Lead, pmkr/AICD combination                      N
C1900    Lead, coronary venous                            N
C2614    Probe, perc lumb disc                            N
C2615    Sealant, pulmonary, liquid                       N
C2616    Brachytx source, Yttrium-90              CH      K      2616          172.2337      10586.86                    2117.37
C2617    Stent, non-cor, tem w/o del                      N
C2618    Probe, cryoablation                              N
C2619    Pmkr, dual, non rate-resp                        N
C2620    Pmkr, single, non rate-resp                      N
C2621    Pmkr, other than sing/dual                       N
C2622    Prosthesis, penile, non-inf                      N
C2625    Stent, non-cor, tem w/del sy                     N
C2626    Infusion pump, non-prog,temp                     N
C2627    Cath, suprapubic/cystoscopic                     N
C2628    Catheter, occlusion                              N
C2629    Intro/sheath, laser                              N
C2630    Cath, EP, cool-tip                               N
C2631    Rep dev, urinary, w/o sling                      N
C2632    Brachytx sol, I-125, per mCi             CH      D
C2633    Brachytx source, Cesium-131              CH      K      2633       1.4779              90.84                         18.17
C2634    Brachytx source, HA, I-125               CH      K      2634       0.5316              32.68                          6.54
C2635    Brachytx source, HA, P-103               CH      K        Milliman 0.8878
                                                                 2635                           54.57                         10.91
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                      61.468            2007 CF
                                                                                                    National             Minimum
HCPCS/                                                                         Relative            Unadjusted            Unadjusted
CPT                  Short Descriptor             CI      SI     APC           Weight Payment Rate Copayment             Copayment
C2636    Brachytx linear source,P-103             CH      K      2636            0.6427     39.51                                7.9
C2637    Brachytx, Ytterbium-169                  CH      B
C8900    MRA w/cont, abd                                  S      0284            6.1231     376.37              148.4             75.27
C8901    MRA w/o cont, abd                                S      0336            5.6745      348.8             139.51             69.76
C8902    MRA w/o fol w/cont, abd                          S      0337            8.1155     498.84             199.53             99.77
C8903    MRI w/cont, breast, uni                          S      0284            6.1231     376.37              148.4             75.27
C8904    MRI w/o cont, breast, uni                        S      0336            5.6745      348.8             139.51             69.76
C8905    MRI w/o fol w/cont, brst, un                     S      0337            8.1155     498.84             199.53             99.77
C8906    MRI w/cont, breast, bi                           S      0284            6.1231     376.37              148.4             75.27
C8907    MRI w/o cont, breast, bi                         S      0336            5.6745      348.8             139.51             69.76
C8908    MRI w/o fol w/cont, breast,                      S      0337            8.1155     498.84             199.53             99.77
C8909    MRA w/cont, chest                                S      0284            6.1231     376.37              148.4             75.27
C8910    MRA w/o cont, chest                              S      0336            5.6745      348.8             139.51             69.76
C8911    MRA w/o fol w/cont, chest                        S      0337            8.1155     498.84             199.53             99.77
C8912    MRA w/cont, lwr ext                              S      0284            6.1231     376.37              148.4             75.27
C8913    MRA w/o cont, lwr ext                            S      0336            5.6745      348.8             139.51             69.76
C8914    MRA w/o fol w/cont, lwr ext                      S      0337            8.1155     498.84             199.53             99.77
C8918    MRA w/cont, pelvis                               S      0284            6.1231     376.37              148.4             75.27
C8919    MRA w/o cont, pelvis                             S      0336            5.6745      348.8             139.51             69.76
C8920    MRA w/o fol w/cont, pelvis                       S      0337            8.1155     498.84             199.53             99.77
C8950    IV inf, tx/dx, up to 1 hr                CH      D
C8951    IV inf, tx/dx, each addl hr              CH      D
C8952    Tx, prophy, dx IV push                   CH      D
C8953    Chemotx adm, IV push                     CH      D
C8954    Chemotx adm, IV inf up to 1h             CH      D
C8955    Chemotx adm, IV inf, addl hr             CH      D
C8957    Prolonged IV inf, req pump               CH      S      0441            2.4851     152.75                             30.55
C9003    Palivizumab, per 50 mg                           K      9003                       609.62                            121.92
C9113    Inj pantoprazole sodium, via                     N
C9121    Injection, argatroban                            K      9121                        17.48                                  3.5
C9220    Sodium hyaluronate                       CH      D
C9221    Graftjacket Reg Matrix                   CH      D
C9222    Graftjacket SftTis                       CH      D
C9224    Injection, galsulfase                    CH      D
C9225    Fluocinolone acetonide                   CH      D
C9227    Injection, micafungin sodium             CH      D
C9228    Injection, tigecycline                   CH      D
C9229    Injection ibandronate sodium             CH      D
C9230    Injection, abatacept                     CH      D
C9231    Injection, decitabine                    CH      D
C9232    Injection, idursulfase                   NI      G      9232                       464.32                                92.86
C9233    Injection, ranibizumab                   NI      G      9233                         2067                                413.4
C9234    Inj, alglucosidase alfa                  NI      K      9234                        127.2                                25.44
C9235    Injection, panitumumab                   NI      K      9235                          84.8                               16.96
C9350    Porous collagen tube per cm              NI      G      9350                       494.53                                98.91
C9351    Acellular derm tissue percm2             NI      G      9351                        44.01                                  8.8
C9399    Unclassified drugs or biolog                     A
C9716    Radiofrequency energy to anu             CH      T      0150     29.6189          1820.61             437.12         364.12
C9723    Dyn IR Perf Img                                  S      1502                           75                                15
C9724    EPS gast cardia plic                             T      0422     25.7552          1583.12             448.81         316.62
C9725    Place endorectal app                             S      1507                          550                               110
C9726    Rxt breast appl place/remov                      S      1508                          650                               130
C9727    Insert palate implants                   NI      S      1510
                                                                   Milliman                    850                               170
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    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007
                                                                                                        61.468      2007 CF
                                                                                                        National     Minimum
HCPCS/                                                                         Relative                Unadjusted    Unadjusted
CPT                 Short Descriptor              CI      SI     APC           Weight     Payment Rate Copayment     Copayment
D0120    Periodic oral evaluation                         E
D0140    Limit oral eval problm focus                     E
D0150    Comprehensve oral evaluation                     S      0330            7.0550        433.66                         86.73
D0160    Extensv oral eval prob focus                     E
D0170    Re-eval,est pt,problem focus                     E
D0180    Comp periodontal evaluation                      E
D0210    Intraor complete film series                     E
D0220    Intraoral periapical first f                     E
D0230    Intraoral periapical ea add                      E
D0240    Intraoral occlusal film                          S      0330            7.0550        433.66                         86.73
D0250    Extraoral first film                             S      0330            7.0550        433.66                         86.73
D0260    Extraoral ea additional film                     S      0330            7.0550        433.66                         86.73
D0270    Dental bitewing single film                      S      0330            7.0550        433.66                         86.73
D0272    Dental bitewings two films                       S      0330            7.0550        433.66                         86.73
D0274    Dental bitewings four films                      S      0330            7.0550        433.66                         86.73
D0277    Vert bitewings-sev to eight                      S      0330            7.0550        433.66                         86.73
D0290    Dental film skull/facial bon                     E
D0310    Dental saliography                               E
D0320    Dental tmj arthrogram incl i                     E
D0321    Dental other tmj films                           E
D0322    Dental tomographic survey                        E
D0330    Dental panoramic film                            E
D0340    Dental cephalometric film                        E
D0350    Oral/facial photo images                         E
D0415    Collection of microorganisms                     E
D0416    Viral culture                                    B
D0421    Gen tst suscept oral disease                     B
D0425    Caries susceptibility test                       E
D0431    Diag tst detect mucos abnorm                     B
D0460    Pulp vitality test                               S      0330            7.0550        433.66                         86.73
D0470    Diagnostic casts                                 E
D0472    Gross exam, prep & report                        B
D0473    Micro exam, prep & report                        B
D0474    Micro w exam of surg margins                     B
D0475    Decalcification procedure                        B
D0476    Spec stains for microorganis                     B
D0477    Spec stains not for microorg                     B
D0478    Immunohistochemical stains                       B
D0479    Tissue in-situ hybridization                     B
D0480    Cytopath smear prep & report                     B
D0481    Electron microscopy diagnost                     B
D0482    Direct immunofluorescence                        B
D0483    Indirect immunofluorescence                      B
D0484    Consult slides prep elsewher                     B
D0485    Consult inc prep of slides                       B
D0502    Other oral pathology procedu                     B
D0999    Unspecified diagnostic proce                     B
D1110    Dental prophylaxis adult                         E
D1120    Dental prophylaxis child                         E
D1201    Topical fluor w prophy child                     E
D1203    Topical fluor w/o prophy chi                     E
D1204    Topical fluor w/o prophy adu                     E
D1205    Topical fluoride w/ prophy a                     E        Milliman
     pai 7/26/2012 2:18 PM
     C:\Docstoc\Working\pdf\1bf99266-e64d-456c-98ff-b3e224125b44.xls\ [ADDB]                                              Page 169 of 706
    ADDENDUM B.--PAYMENT STATUS BY HCPCS CODE AND RELATED
               INFORMATION CALENDAR YEAR 2007